Surgical palliation for malignant disease requiring locoregional control.

BACKGROUND: Surgical palliation of cancer is best defined as procedures performed with non-curative intent to improve quality of life or control symptoms of advanced malignancy. Soft tissue involvement of advanced malignancies may produce symptoms such as pain, bleeding, or odor that significantly reduce quality of life. Literature on outcomes of palliative resection of soft tissue malignancy for local or regional control is lacking. METHODS: Soft tissue resections performed with palliative intent for locoregional control were identified from a prospectively maintained palliative surgery database at a tertiary care center from January 2004 to July 2013. Tumor type, presenting symptom, procedure performed, and symptom recurrence were recorded. Patients were followed for at least 60 days or until death. RESULTS: Thirty-one patients who underwent palliative soft tissue resection for local control were identified. Primary tumor types included melanoma (n=9, 29.0%), squamous cell carcinoma (n=9, 29.0%), sarcoma (n=5, 16.1%), breast (n=3, 9.7%), and other (n=5, 16.1%). Eighteen of 31 patients (58.1%) underwent resection for pain, two (6.5%) for bleeding, and eleven (35.5%) for local control or other symptoms. Procedures were performed on the trunk (n=17, 54.8%), extremities (n=7, 22.6%), head/neck (n=5, 16.1%), or multiple areas (n=2, 6.5%). Eleven of 31 patients (35.5%) underwent axillary, inguinal, or neck lymph node dissection, seventeen (54.8%) radical resection, and three (9.7%) wound excision. Split-thickness skin graft was performed in 6 of 17 radical resections (35.3%). Five patients (16.1%) had symptom recurrence at the site of the initial palliative procedure, of whom four (12.9%) underwent a second palliative procedure. Seven patients (22.6%) had new disease-related symptoms develop during follow-up. Thirty-day morbidity was 29.0%; mortality was 3.2%, which was associated with progression of disease. CONCLUSIONS: Palliative surgery for local control of advanced soft tissue malignancy can provide durable symptom relief and improved quality of life. These procedures positively impact patients regardless of primary tumor type or tumor extent. Careful patient selection is important in order to maximize benefit of surgical palliation and minimize morbidity and mortality.

Survey field methods for expanded biospecimen and biomeasure collection in NSHAP Wave 2.

OBJECTIVES: The National Social Life, Health, and Aging Project is a nationally representative, longitudinal survey of older adults. A main component is the collection of biomeasures to objectively assess physiological status relevant to psychosocial variables, aging conditions, and disease. Wave 2 added novel biomeasures, refined those collected in Wave 1, and provides a reference for the collection protocols and strategy common to the biomeasures. The effects of aging, gender, and their interaction are presented in the specific biomeasure papers included in this Special Issue. METHOD: A transdisciplinary working group expanded the biomeasures collected to include physiological, genetic, anthropometric, functional, neuropsychological, and sensory measures, yielding 37 more than in Wave 1. All were designed for collection in respondents' homes by nonmedically trained field interviewers. RESULTS: Both repeated and novel biomeasures were successful. Those in Wave 1 were refined to improve quality, and ensure consistency for longitudinal analysis. Four new biospecimens yielded 27 novel measures. During the interview, 19 biomeasures were recorded covering anthropometric, functional, neuropsychological, and sensory measures and actigraphy provided data on activity and sleep. DISCUSSION: Improved field methods included in-home collection, temperature control, establishment of a central survey biomeasure laboratory, and shipping, all of which were crucial for successful collection by the field interviewers and accurate laboratory assay of the biomeasures (92.1% average co-operation rate and 97.3% average assay success rate). Developed for home interviews, these biomeasures are readily applicable to other surveys.

Elevated C-reactive protein as a predictor of patient outcomes following palliative surgery.

BACKGROUND AND OBJECTIVES: Optimal surgical decision-making and informed consent for palliative procedures is limited by a lack of appropriate outcomes data. Elevated C-reactive protein (CRP) may help guide patient selection for palliative surgery. METHODS: Procedures to palliate symptoms of advanced cancer were identified from a prospective palliative surgery database. Patients with a recorded preoperative serum CRP were identified and observed for at least 180 days or until death. RESULTS: Fifty patients were identified who underwent an elective palliative procedure from July 2006 to June 2012. Presenting symptoms included gastrointestinal obstruction (40%), tumor-related pain (38%) or bleeding (12%), and other (10%). Symptom improvement was documented for 37 patients (74%). Palliative procedures were associated with 30-day postoperative morbidity (42%) and mortality (10%). CRP (range 1-144 mg/L, median 9.7 mg/L) was elevated in 27 patients (54%) and was independently associated with developing a major complication (P = 0.005) and decreased overall survival (166 vs. 659 days, P < 0.0001). CONCLUSIONS: Patients with advanced cancer can be afforded symptom improvement and the opportunity for improved quality of life following palliative procedures. Elevated preoperative CRP may help identify patients who are less likely to realize the benefits of palliative operations.

Continuity and innovation in the data collection protocols of the second Wave of the National Social Life, Health, and Aging Project.

BACKGROUND: The second Wave (W2) of the National Social Life, Health, and Aging Project (NSHAP), a nationally representative, longitudinal survey of older adults now between the ages of 62 and 90, conducted approximately 3,400 interviews. Selected coresidential romantic partners as well as W1 panel nonrespondents were selected for W2. Data collection included in-person questionnaires, up to 15 biomeasures, and a post-interview questionnaire. METHODS: A proxy questionnaire also collected data on respondents that were deceased or in too poor health to participate in W2. Biomeasure collection included height, weight, hip and waist circumference, blood pressure, heart rate, and preventricular contraction, timed walk and chair stands, smell, saliva collection using a Salivette (cortisol), saliva passive drool in a tube (dehydroepiandrosterone, estradiol, progesterone, testosterone), dried blood spots (Epstein-Barr virus antibody titers, C-reactive protein, glycosylated hemoglobin, hemoglobin, cholesterol, high-density lipoprotein), whole blood in a microtainer (cytokines), urine (creatinine, vasopressin, oxytocin), Oragene (genotype), respondent-administered vaginal swabs (bacterial vaginosis,yeast, and vaginal cell cytology), and Actiwatch (sleep patterns and activity). RESULTS: Measures, such as response and cooperation rates, are also provided to evaluate design and implementation. DISCUSSION: This article describes both innovation in the development and implementation of W2 as well as fidelity to W1 study design and data collection procedures.

The palliative triangle: improved patient selection and outcomes associated with palliative operations.

OBJECTIVES: To examine the outcomes of patients managed with the palliative triangle method and to evaluate factors associated with effective patient selection. DESIGN: Patients receiving a procedure to palliate symptoms of advanced cancer were identified prospectively from all surgical palliative care consultations and observed for at least 90 days or until death. SETTING:   Academic surgical oncology service. PATIENTS: A total of 227 patients symptomatic from advanced incurable cancer. INTERVENTION: The palliative triangle technique was used to select patients for palliative operations. MAIN OUTCOME MEASURES: Symptom resolution, overall survival, and complications. RESULTS: We evaluated 227 patients from July 1, 2004, through June 30, 2009. Reasons cited for not selecting 121 patients (53.3%) for a palliative procedure were low symptom severity (23.9%), decision for nonoperative palliation (19.0%), patient preference (19.8%), concerns about complications (15.7%), and other (21.6%). A palliative operation was performed in 106 patients (46.7%) for complaints of gastrointestinal obstruction (35.8%), local control of tumor-related symptoms (25.5%), jaundice (10.4%), and other (28.3%). Of these 106 patients, 5 required procedures for recurrent symptoms and 6 for additional symptoms; of the 121 patients originally not selected, 12 required procedures for progressive symptoms, for a total of 129 procedures. Patient-reported symptom resolution or improvement was noted in 117 of 129 procedures (90.7%). Palliative procedures were associated with 30-day postoperative morbidity (20.1%) and mortality (3.9%). Median survival was 212 days. CONCLUSION: Palliative operations performed in these carefully selected patients were associated with significantly better symptom resolution and fewer postoperative complications compared with previously published results.