Palliative surgical intervention in advanced colo-rectal cancer: A prospective analysis of symptoms relief and quality of life

Abstract

Introduction: An estimated 40-70% of patients with metastatic CRC are symptomatic from the primary tumour at the time of diagnosis. Nearly 30% of patients with colorectal cancer patients present with acute intestinal obstruction. Conservative treatment is often unsuccessful in most patients so surgical intervention becomes unavoidable. In this study, we prospectively evaluated the impact of palliative surgery on symptom relief, surgical morbidity and analyzed patient outcomes of palliative surgery by using validated tools of outcome measurements. Methods: Treatment planning for patients with advancedmalignancies will be done inmultidisciplinary tumour board. All patients requiring palliation of symptoms and likely to obtain symptomatic relief from the proposed operation was planned for palliative surgery. Patient and familymembers were counselled about stage of disease and intent of surgery. At the time of enrolment, demographic variables were documented. Quality of life (QOL) and symptoms relief were used for assessment of outcomes. QOL was assessed by the Functional Assessment of Cancer Therapy-General (FACT-G) tool and severity of symptoms was assessed by symptoms distress score (SDS).All patients were followed upto 3months after surgery. FACT G score and symptoms distress score was documented at baseline (before surgery), onemonth and 3months after surgery. Results: Twenty four patients of advanced colorectal cancers included in the study. Majority of patients had carcinoma rectum (n =16).Most of the patients presented with acute or sub-acute intestinal obstruction. Majority of patients underwent palliative proximal diversion ostomy. Indications and spectrum of palliative procedures performed are tabulated in table 1. Mean post-operative hospital stay was 4.5 days. Immediate post-operative mortality occurred in one patient. Post-operative morbidity documented in 5(21%) patients. Most common morbidity was surgical site infections (n =3). Four patients re-admitted within 3 months of follow up. Mean period of re-admission was 2.5 days.Most common indication for re-admission was narcotic drugs dose titration for severe pain. At the end of 3months of follow up for each patient, 18(70%) patients were alive with disease, 5(20%) lost to follow up and 3(11%) patients died due to disease. All patients who completed the 3 months of follow up had statistically significant improvement in QOL score, both from base line to one month post-operative period as well as from 1month to 3 months of post-surgery (table 2, figure 1).All the subscales ofQOL improved from palliative surgery. Greatest augmentation was seen in physical wellbeing than the other sub scales of QOL (Fig 2). As most of the patients presented with intestinal obstruction, palliative diversion stoma resulted in immediate relief of symptoms. Further, symptoms distress score declined significantly both at 1month and 3 months of post-surgery (Table 3, Fig 3). Conclusion: Intestinal obstruction is the commonest indication for palliative surgery in advanced colorectal cancer. Acceptable postoperative complications similar to curative surgeries can be achieved by protocol based multidisciplinary treatment planning. Palliative surgeries in carefully selected patients results in resolution of symptoms and improvement of quality of life.