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RESEARCH • RECHERCHE

Does regional variation impact decision-making in
the management and palliation of pancreatic head
adenocarcinoma? Results from an international
survey
Valerie Hurdle, BSc* Background: Management and palliation of pancreatic head adenocarcinoma is chal-
Jean-Francois Ouellet, MD† lenging. End-of-life decision-making is a variable process involving multiple factors.

Elijah Dixon, MD, MSc* Methods: We conducted a qualitative, physician-based, 40-question international survey
characterizing the impact of medical, religious, social, training and system factors on care.
Thomas J. Howard, MD‡
Keith D. Lillemoe, MD§ Results: A total of 258 international clinicians completed the survey. Respondents were
typically fellowship-trained (78%), with a mean of 16 years’ experience in a university-
Charles M. Vollmer, MD¶ affiliated (93%) hepato-pancreato-biliary group (96%) practice. Most (91%) believed
Francis R. Sutherland, MD* resection is potentially curative. Most patients were discussed preoperatively by multi-
disciplinary teams (94%) and medical assessment clinics (68%), but rarely critical care
Chad G. Ball, MD, MSc* (21%). Intraoperative surgical palliation included double bypass or no intervention for
locally advanced nonresectable tumours (41% and 49% v. 14% and 85%, respectively,
From the *Department of Surgery, Uni- for patients with hepatic metastases). Postoperative admission to the intensive care unit
versity of Calgary, Calgary, Alta, †Depart- was frequent (58%). Severe postoperative complications were often treated with aggres-
ment of Surgery, Laval University, Que- sive cardiopulmonary resuscitation, intubation and critical care (96%), with no defined
bec City, Que., ‡Department of Surgery, time points for futility (74%). Admitting surgeons guided most end-of-life decisions
Community Health Network, Indianapo- (97%). Formal medical futility laws were rarely available (26%). Insurance status did not
lis, Ind., §Department of Surgery, Har- alter treatment (97%) or palliation (95%) in non–universal care regions. Clinician ex-
vard University, Massachusetts General perience, regional culture and training background impacted treatment (all p < 0.05).
Hospital, Boston, Mass., and the
¶Department of Surgery, University of Conclusion: Despite remarkable overall agreement, geographic and training differ-
Pennsylvania, Philadelphia, PA. ences are evident in the treatment and palliation of pancreatic head adenocarcinoma.

Presented at the Americas Hepato-
Pancreato-Biliary Association Annual Contexte : Le traitement et les soins palliatifs pour l’adénocarcinome de la tête du
Meeting, Feb. 24, 2013. pancréas sont complexes. Les décisions de fin de vie reposent sur un processus haute-
ment variable qui dépend de multiples facteurs.
Accepted for publication Méthodes : Nous avons administré à des médecins un sondage international quali-
June 17, 2013 tatif à 40 questions afin de caractériser l’impact sur les soins exercé par différents fac-
teurs, notamment médicaux, religieux, sociaux, relatifs à la formation et systémiques.
Correspondence to:
C.G. Ball Résultats : En tout, 258 cliniciens ont participé à ce sondage international. Les partici-
Department of Surgery pants étaient en général des spécialistes (78 %), cumulaient en moyenne 16 ans d’expéri-
Foothills Medical Centre ence dans le domaine hépatopancréatobiliaire (96 %) au sein d’un groupe affilié à une
1403-29 St N.W. université (93 %). La plupart (91 %) ont dit croire que la résection est potentiellement
Calgary, AB T2N 2T9 curative. La majorité des cas faisaient l’objet de discussions préopératoires par des équipes
ball.chad@gmail.com multidisciplinaires (94 %) et en clinique d’évaluation médicale (68 %), mais rarement par
une équipe de soins intensifs (21 %). Les soins palliatifs chirurgicaux peropératoires
incluaient la double dérivation ou la non intervention en présence de tumeurs non résé-
DOI: 10.1503/cjs.011213 cables localement avancées (41 % et 49 % c. 14 % et 85 %, respectivement, chez les
patients porteurs de métastases hépatiques). L’admission postopératoire aux soins inten-
sifs a été fréquente (58 %). Les complications postopératoires graves étaient souvent
traitées par réanimation cardiorespiratoire énergique, intubation et soins intensifs (96 %),
sans critères chronologiques de futilité définis (74 %). C’est aux chirurgiens traitants que
revenait la plupart des décisions de fin de vie (97 %). Peu avaient accès à des consignes
formelles au sujet de la futilité des interventions médicales (26 %). La couverture d’assur-
ance n’a modifié ni le traitement (97 %) ni les soins palliatifs (95 %) dans les régions où
les soins n’étaient pas universels. L’expérience des médecins, la culture régionale et la for-
mation de base ont eu un impact sur le traitement (toutes, p < 0,05).
Conclusion : Malgré une concordance remarquable, des différences géographiques et
des différences liées à la formation ont eu un impact sur le traitement et les soins palli-
atifs pour l’adénocarcinome de la tête du pancréas.

© 2014 Canadian Medical Association Can J Surg, Vol. 57, No. 3, June 2014 E69

training and sys. religious. atheist 6%. Columbia and Japan. the primary goal of The respondents reported considerable experience in the this study was to better understand the end-of-life process management of head PDAC. The authors of this 40-question Respondents reported significant diversity within their survey consisted of hepato-pancreato-biliary (HPB) sur. resided in the United States (40%).38 Ques.1.7–38 It is best described as a varied significantly across countries (94%). The fact disease at the time of operative exploration. 3 sur- We created a qualitative international survey outlining end. many of these patients die relatively late during their hos- pital course after undergoing highly sophisticated surgical RESULTS and/or medical rescue therapies. Norway. While tremely complex and variable process on the part of both most clinicians believed that end-of-life decision-making clinicians and family members.2 end-of-life issues (AHPBA). Africa). specialists in intensive care medicine. Canada (16%). The survey was available for completion from Jul. Statistical analysis primarily involved fre- in the hospital setting can also be difficult for clinicians. The HPB surgeons typically rehabilitation therapists from various regions throughout and concurrently treated patients with gastrointestinal the world (Canada. Each member was also asked arise following either severe and immediate postoperative to forward the survey link to additional surgical contacts complications or delayed recurrence of the disease itself. 2 HPB surgeons 18%. Jewish impact of medical. Most surgeons (78%) were following resection of head PDAC (pancreaticoduodenec. Reported religious beliefs (or lack thereof) were diverse tions were created with the intent of characterizing the among clinicians (Christian 58%. personal beliefs. South trophic general surgical emergency. Results were anonymous. Africa (5%) and Mexico (4%).1 This pur- ports both depressing patient prognosis as well as frustrating experiences on the part of clinicians.RECHERCHE ancreatic ductal adenocarcinoma (PDAC) is clearly included specific scenarios for patients with nonresectable P among the most aggressive of all cancers. Brazil icians and patients who sustain major trauma or a catas. and that the annual death rate approaches incidence speaks to once completed they were sequentially forwarded to the the dismal natural history of this disease. 2012. Finland. they completed their HPB postgraduate training.ca). and was limited to HPB surgeons. Canadian Hepato-Pancreato-Biliary Association remain prevalent within this population. (CHPBA). 57. authors in real time. This pattern was not affected by country or culture. Given the relative paucity of research focused on end-of-life care for patients with PDAC. intact functional and mental status as well as a long-term New Zealand. end-of-life concerns typically other HPB-related societies. clinical practices. It should oncology (28%). Advertisement of the survey to potential respondents cant improvements in surgical technique and perioperative was achieved via standardized email notifications to mem- care that have dramatically lowered 30-day mortality to bers of the Americas Hepato-Pancreato-Biliary Association less than 5% in high-volume centres. Additional survey respond- patients with PDAC often enter the operating theatre with ents practised in Italy. The study also atheism than any major religion. Most respondents ship is fundamentally different from that between clin. Both Canada tem elements on end-of-life care for patients with PDAC and Europe had more respondents report agnosticism or in various geographic regions/countries. available at canjsurg.3–6 It is also clear that the psychological component of the patient–clinician relation. N 3. agnostic 17%. geons 18%. as well as to limi. Respondents from the o E70 J can chir. more than 4 surgeons 42%). A total of 258 surveys were completed. dix. social. of-life issues for patients with head PDAC (see the Appen. Despite signifi. Few surgeons (33%) limited their prac- geons. 1. More specifically. Germany (5%). societal norms. authors within the trauma/critical care community. and they had a mean of 16 (range 0–43) years’ experience in university-affiliated teaching hospitals (93%). ethical. local governmental bodies) to direct practice (26%).2 with a potential interest in end-of-life care for patients Providing appropriate and compassionate end-of-life care with PDAC. 4 surgeons 18%. Most HPB surgeons (94%) worked in the country where It is evident that end-of-life decision-making is an ex. the Netherlands. general surgery (25%) or surgical oncol- be noted that this survey is an extension of similar work by ogy (14%) issues. relationship with their surgeons. 1 to Sept. (15%). predicted functional outcomes. Australia. fellowship-trained in HPB surgery (39%). few respond- nonlinear sequence that may include factors such as patient ents had formal medical futility laws or guidelines (from prognosis. HPB transplan- tomy) by highlighting the differences and similarities among tation (10%) or surgical oncology with HPB training ele- clinician viewpoints from various countries and backgrounds. bioethicists and tices to pure HPB diagnoses. Europe. 8%. as quency distributions. ments (29%). personal experience and the rehabilitation and support network available upon Clinicians discharge. institutional resources. United States. METHODS Most respondents also had at least 2 HPB colleagues at their institutions (solo 4%. tations in our current treatment options. juin 2014 . The Pancreas Club and to various members of In the context of PDAC. Hindu 3%. the United Kingdom (8%). Argentina. Vol. Buddhist 3%).

More specifically. Surgeons displayed varied tices regarding end-of-life decisions/beliefs had changed use of routine consideration for neoadjuvant (chemo- with experience. More specifically. Medical comorbidities alone were the intensivists regarding critical care admission and therapies dominant deciding factor for operative selection (79%). all respondents was low (21%). necessary. p < 0. p < 0. Canadian and South African surgeons more fre- for resection. 40% of respondents found this service always or usually helpful. While agreement among respondents was similar overall. regardless of country. The majority of surgeons also with a high risk of tumor recurrence” (92%). reported that resource limitations influenced their States had the highest rate of routine postoperative ICU end-of-life decisions for patients with PDAC. tomy was also common (69%) across all countries. respectively. including cardiopulmonary resuscitation. used than respondents in all other countries (9%. it is evident that Most surgeons (92%) considered resection and/or recon- surgeons with surgical oncology training reported signifi. When ethics (95%) and Brazil (91%) received significantly more surgical services were available. 57. p < 0. training used routine neoadjuvant therapies more com- tutions (89% infrequently or never differed). No.001). routine preoperative multidisciplinary oncology confer.001). Regardless of country. Many (71%) reported that their opinions and prac. Despite always or selectively admitting patients to the ICU ents denied that patient insurance status impacted either following pancreaticoduodenectomy (33% and 25%. the use of preoperative critical care consultation across and 83% of surgeons in Brazil and South Africa. the admitting surgeon (97%) typically gastric bypasses (double bypass). Most clin. 3.4%) considered to be the most import. respec- treatment (97%) or palliation (95%) decision-making. where 53% of end-of-life decisions in geneity observed for patients with locally unresectable the intensive care unit (ICU) were directed by the critical tumours who often (41%) received operative biliary and care physician. and 33% respectively. The need to monly than HPB-trained surgeons (p = 0. Concurrent chemical splanchnicec- (16%). respectively. discuss patient issues of relevance.and/or HPB transplantation– patients who were found to have hepatic metastases or peri- trained surgeons (43% v. Although most respond. toneal carcinomatosis with no preoperative gastric outlet or biliary obstruction were most commonly (85%) managed Institutions with nonsurgical approaches (biliary and duodenal stenting on demand). ity ranged widely. In the operative setting. only surgeons from Germany and Italy dif. struction of the portal vein an important part of their prac- cantly more frequent disagreement with colleagues at their tice in achieving negative margins.001). Respondents in the United tively. Vol.05). When clinicians did use them. 3%. with no specific time points to define futility ant factor in deciding who was an appropriate candidate (74%). regarding end-of-life care for patients with PDAC were in surgeons who defined themselves with surgical oncology consistent agreement with those of colleagues at their insti. most institutions for unresectability. Patient age considered continuing critical care (ICU) for as long as alone was rarely (0. Most surgeons followed their postoperative patients with ences (94%) and medical/anesthesia assessments (68%) to scheduled outpatient visits in addition to radiological and Can J Surg. respec. quently considered time-based end points for withdrawing lutely irrelevant among 54% of responders (40% con. 47% tively). admission compared with Canada (78% v. The remaining Postoperative care surgeons found it occasionally or never helpful (34%) or refused to use the service (25%). Canadian sur- sidered age an important factor when the patient was geons also reported more resistance (45%) from their older than 80 yr). but did not differ statistically changed over time). transfer the care of a patient to a different physician/ surgeon because of conflicts with the patient’s family Operative technique and palliation regarding end-of-life care was rare (6%). radiotherapy) therapies (57%). age was defined as abso. Mexico also offered ethics consultation services (93%). Regardless of the rationale retained control. p = 0. This differed significantly from the hetero- Except in Canada. 6%. South Africa) influence the end-of-life care provided to their patients used medical/anesthesia assessments less commonly (21% (92%). p = 0. transfer to the ICU and prolonged critical care for PDAC a potentially curative procedure (91%) and admission if necessary. patients in South Africa (100%). Regardless of country. institutions than either HPB. care (57% and 50%.009).05).004). June 2014 E71 . for patients who underwent a pancreaticoduodenectomy The majority of surgeons. No respondent indicated a prefer- described it to patients as a “potentially curative operation ence for comfort care only. RESEARCH United States were primarily Christian (87%). Only surgeons in icians also believed their individual faith/religion did not resource-challenged environments (Brazil. their interpreted util. Severe postoperative complications following pancreati- Preoperative preparation coduodenectomy were most commonly (96%) treated with aggressive care. a minority of respondents used them bypasses (all p < 0. This was clearly limited to fered (67% in each country felt their beliefs had not resource-plentiful countries. Most respondents considered pancreaticoduodenectomy intubation. Most clinicians also felt their opinions among these regions (all p > 0.005).

proportion of training paradigms. as well as the import- ferent subspecialties and etiologies. States (78%) likely reflects both the reality that these units Unlike many explorations of end-of-life care among dif. reason- in the United States. tional HPB surgeons displays remarkable similarities across It is interesting to note a clear association between countries and regions. Canadian (53%) and Italian (100%) surgeons were most likely reflects the reality that the majority of surgical most likely to defer these detailed discussions until the critical care in Canada is provided by highly skilled nonsur- patient had met with a medical oncologist (p < 0.19–21. therefore. ance of generating revenue in an open-market system. resources and technol. Mexico) a similar author-based study in the trauma/critical care and a higher rate of surgical bypasses (biliary and gastric) field. 57. This (29%). nonsurgeon) efficacy for adjuvant chemotherapy was also common (65%). surgical oncologists also ents’ regions could be separated into 2 groups based on reported an increased rate of discordance with their col- religion.38–40 Unfortunately. geon intensivists. Vol. include interaction with an experienced. limitations on clinical and end-of-life decisions for HPB- tion. N 3. Surgical assessment of patient risk is based on medical related neoplasms within these countries. This is consist. it in unresectable scenarios as well as a significantly higher was also clear that surgeon end-of-life care had changed rate of routine postoperative ICU admission. The explanation ogy. from a medical futility law allowing them to proceed with o E72 J can chir. In addition to making up the smallest on both doctor and patient religion. very few of the observed differences in cases of both locally unresectable and distantly metasta- were based on the country of practice. This finding differs significantly from resource-challenged regions (South Africa. able extent of surgical resection and/or reconstruction ent with the United States being one of the most religious and/or the biology of disease itself. end-of-life decision-making as well as resistance regarding with deferral to the medical oncologist being less frequent aspects of this care with their intensivist colleagues. there were more religious cohorts in the perceived efficacy of neoadjuvant therapies. Further with increasing clinical experience. Despite this remarkable and extensive global agreement. religion.31–35.11–13. time-based end points for initiating with- between societal norms.41 As would be expected also displayed a lower rate of chemical splanchnicectomy with such a high level of experience among respondents. Although Canada also displayed the lowest rate of routine postoperative ICU admission (3%). greater support for their individual faith influenced the end-of-life care they pro. (2) more frequent participation in preceding neoad- countries (94%). to certain aspects of critical care. surrounded differences based on the training fellowship of Neoadjuvant therapy. or (3) being partial to the greater emphasis on vided to patients. as a result. Physician beliefs regarding end-of-life care vary by country It may also provide an opportunity to discuss the reported and background as a result of a complex interaction use of defined.29.RECHERCHE biochemical surveillance (74%). More specifically. this fric- DISCUSSION tion may reflect a need to pursue more frequent preopera- tive critical care assessments and therefore communication. It also clearly supports the self-reported impact of resource geon in an academic practice with plans for a curative resec. juin 2014 . results.. HPB surgeons who identified and/or surgical palliation (including celiac plexus block) of themselves as having completed a surgical oncology fel- locally advanced PDAC found intraoperatively is available. as guided by HPB or HPB-transplant surgeons. This Canada.29 Our study respond.8. While a statistical majority of respondents in leagues regarding institutional treatment of PDAC. this survey of interna. the typ. Canadians were much Communication of specific values and data regarding the more likely to report intensivist-dictated (i. it may assistance from ethics consultation services. This contradicts the findings of a large neoadjuvant therapies displayed at surgical oncology– European study that detected significant differences based based conferences. For example. Europe. to our knowledge. this for such high postoperative ICU admissions in the United concept has not been explored in patients with head PDAC. Others used outpatient vis.e. greater use of multimodality thera- that treatment of HPB-related neoplasms varied across pies. few respondents benefited notable differences mandate discussion.001). most clinicians denied that their own juvant trials and. head PDAC than their colleagues who were trained as sive rescue critical care of undefined duration. This likely reflects limited access to postoper- ical care algorithm of a patient with head PDAC would ative endoscopic and/or percutaneous stenting techniques. tic tumours. are managed by surgeon–intensivists. drawal of care among Canadian patients. study is required to explain these observations. South Africa and Asia. HPB-trained sur. lowship more commonly used neoadjuvant therapies for Severe postoperative complications are treated with aggres. On an institutional level. comorbidities (not age) as well as a medical assessment clinic The most intriguing heterogeneity among respondents after discussion at a multidisciplinary oncology conference. Canadian surgeons appear to represent outliers with regard its with (15%) or without (11%) biochemical surveillance. Brazil. portal vein resection/reconstruction origin.38 More specifically. Surgical oncologists nations in the developed world. Although we cannot the admitting surgeon rather than by medical futility laws or definitively identify the reason for this discrepancy. reflect (1) a closer faculty relationship with medical oncol- Although study respondents almost universally agreed ogy and. Australia and New Zealand described observation is very interesting and may reflect differences themselves as agnostic. More specifically.

ETHICATT study. Prendergast TJ. A root-cause analysis of directives. Drebin JA.9:81-5. As a result. Lewis R. et al. Vollmer and 21. et al. CMAJ 1991. Differences in mortality beliefs and values in North America. Murphy PA.71:512-6. Crit Care Med 1992. nurses. decision-making). Cohen SL. the accurate critical care professionals concerning forgoing life-sustaining treat- generalizability of this study is unknown. 17. Dixon. Dixon. Decisions to limit or con- tinue life-sustaining treatment by critical care physicians in the CONCLUSION United States: conflicts between physicians’ practices and patients’ wishes. care at the end of life in the United States: an epidemiologic study. Knox RA. Taylor MD.35.20:320-6. Sprung CL. A cross-cultural comparison of C. Callery MP. opinions among physicians (< 10%). (only 17% to 44% of families are involved in end-of-life 346:1128-37. Linde-Zwirble WT. Meyer W. 13. Barnato AE. 12. N Engl J Med 2002. Sjokvist P. JAMA 1992. Crit Care Med 2001. 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