American College of Surgeons National Surgical Quality Improvement Program as a quality-measurement tool for advanced cancer patients

Posted On 2015-12-21 15:51:45

Surgical palliation refers to the deliberate use of a procedure in a patient diagnosed with incurable malignancy with the intention of relieving symptoms, minimizing patient distress, and improving quality of life (1-3). These procedures play invaluable roles in patients with disseminated malignancy, and at high volume cancer centers, may account for 6-21% of all surgical interventions (4-8). With appropriate counseling and patient selection, symptom resolution can be achieved in as many as 80% of patients (5,9). The relief of intractable pain, bleeding, and intestinal obstructions, among other debilitating symptoms, allows patients to be comfortable and retain an acceptable level of functionality. Despite the success of most palliative operations, approximately 25% of patients will require further interventions for new or recurrent symptoms (5,9). Post-operative complications can present in as many as 40% of patients and overall mortality can reach 23%, mostly secondary to the advanced disease and associated comorbidities (5,6,8). It has been demonstrated that even when prolonged symptom relief is not obtained, these patients do not experience a reduction in quality of life (10). Given the potential risks, decisions regarding the use of surgical procedures for palliation in patients diagnosed with advanced and incurable cancer require a thorough understanding of surgical outcomes data and the highest level of surgical judgment (11,12).

With the onset of surgical quality improvement initiatives, much attention has been placed on data collection to objectively measure and compare surgical outcomes (13). These data are obtained across the United States as part of well-structured databases such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Data within ACS-NSQIP is collected and analyzed under rigorous guidelines, by trained personnel, at every participating institution. For each contributing hospital, approximately 20% of all surgical patients and 136 variables are captured and analyzed (14).

When applied to patients with advanced malignancy, the database allows for identification of cancer-related operations if they meet the “Disseminated Cancer” criterion. Per ACS-NSQIP guidelines, these include patients diagnosed with “cancer that has spread to one site or more sites in addition to the primary site”, or the “presence of multiple metastases which indicate the cancer is widespread, fulminant, or near terminal” (14). No further characterization is made regarding the intent of the operation. Documenting surgical intent for patients with advanced malignancy is of utmost importance when analyzing outcomes data. It has been demonstrated previously that failure to do so limits the appropriate analysis of postoperative morbidity and mortality (2,6,15,16).

The Surgical Risk Calculator was developed using data collected within ACS-NSQIP over a 3-year period, from 2009 to 2012 (17). This tool provides surgeons with information pertaining to the risk of post-operative morbidity and mortality for a particular operation. The calculator allows for easy access to patient-specific data that may aid in clinical decision-making, operative planning, or as an adjunct when counseling patients and family. Authors have proposed using the ACS-NSQIP database in the development of risk calculators, or as a tool for clinical decision-making in the advanced cancer patient (7,18,19). For various particular patient groups, outcomes have already been compared utilizing ACS-NSQIP data and specialty- and procedure-specific databases; yet, no validation has been performed for patients diagnosed with advanced cancer (20). In this study we seek to define the role of ACS-NSQIP data when used for risk-stratification in the advanced cancer patient, particularly those undergoing operations with palliative intent.