Researchers have compared the efficacy of surgical and nonsurgical interventions for patients with malignant bowel obstructions, according to a recent study published by Krouse et al in The Lancet Gastroenterology & Hepatology. The new findings may help to inform clinical decision-making in the management of patients with advanced cancer.
Background
Partial or complete blockage of the bowel, most often the small intestine, is a common complication for patients with advanced abdominal tumors—particularly for those with ovarian or colorectal cancer. Bowel obstruction can be caused directly by tumors, adhesions, or other issues arising from surgery or radiation treatment.
In addition to being potentially life-threatening, malignant bowel obstruction may cause considerable suffering; reduce patients’ quality of life; and result in symptoms such as vomiting, pain, and constipation. Patients who have these obstructions are typically facing end-stage cancer and receiving primarily palliative care.
Physicians treating malignant bowel obstructions have two primary options: surgical management or nonsurgical medical management. However, evidence that can help them to determine which approach may be the most effective is still limited.
“We knew enrolling patients in the hospital with this acute issue and advanced cancer would be difficult, but the questions are of great importance to clinicians, patients, and families,” stressed lead study author Robert S. Krouse, MD, Professor of Surgery at the Perelman School of Medicine at the University of Pennsylvania and Chief of Surgery at the Corporal Michael J. Crescenz Veterans Affairs Medical Center.
Study Methods and Results
In the recent S1316 study, the researchers enrolled 221 patients with malignant bowel obstructions who were candidates for surgery—199 of whom met the criteria for inclusion in the analysis. At registration, the patients were offered the choice of randomization to the surgical group or nonsurgical group. About 25% of them selected randomization. Patients who chose not to undergo randomization decided with their physicians whether to undergo surgical or nonsurgical intervention. About 40% of these patients opted for surgery.
The researchers defined the primary outcome as a measure they termed “good days,” defined as the number of days the patients were alive and out of the hospital. After a follow-up of 91 days after registration, the researchers found the number of good days and the patients’ ability to eat after 5 weeks did not vary significantly between the surgical and nonsurgical groups.
Other secondary measures, however, suggested that surgical interventions resulted in improvements in malignant bowel obstruction–related symptoms. On average, the patients who underwent surgical interventions demonstrated improved symptom severity scores for vomiting, constipation, nausea, and pain after 4 weeks compared with the patients who underwent nonsurgical interventions. Among the patients hospitalized for malignant bowel obstructions, those who underwent surgery also reported fewer symptoms after leaving the hospital.
Conclusions
“Based on the results, we believe surgically eligible patients with [malignant bowel obstructions] should be offered an operation earlier in their hospital stay to improve their symptoms, even though these results suggest it will not increase their number of days alive and out of the hospital,” Dr. Krouse advised. “We are continuing to analyze the data to allow us to make recommendations to clinicians regarding the optimal operations and other quality-of-life factors that may be impacted by the type of treatment received. Our network of institutions and investigators will allow us to examine other important questions in this population of cancer survivors,” he concluded.
Disclosure: The research in this study was supported by a grant from the Agency for Healthcare Research and Quality, the National Cancer Institute through the Division of Cancer Prevention’s NCORP Research Base grant, and the BMISR grant. For full disclosures of the study authors, visit thelancet.com.
