Surgical treatment intensity at the end of life in patients with cancer: a systematic review

Objective
To synthesise evidence of surgical treatment intensity, defined as a measure of the quantity of invasive procedures, received by patients in patients with cancer within a defined time period around the ‘end of life’ (EoL).

Background
Concern regarding overly ‘aggressive’ care or high health care utilisation at the EoL, particularly in cancer, is growing. The contribution surgery makes to the quality and cost of EoL care in cancer has not yet been quantified.

Methods
This PROSPERO registered systematic review used PRIMSA guidelines to search electronic databases for observational studies detailing surgical intensity at the end of life in adult cancer patients. Intensity was compared by disease, individual characteristics, geographical region and palliative care involvement. A risk of bias tool assessed quality and a narrative synthesis of findings was completed.

Results
39 papers were identified in this search. Up to 79% of patients underwent invasive procedures in the last month of life. Heterogeneity in patient groups, inclusion criteria and EoL time periods lead to huge variation in results, with treatment intention often not identified. Patient, geographical and pathological factors, alongside involvement of palliative/hospice care, were all identified as contributors to treatment intensity variation.

Conclusions
A significant proportion of patients with cancer undergo invasive and costly invasive procedures at the EoL. There is significant reporting heterogeneity, with variation in patient inclusion criteria and EoL timeframes, demonstrating uncertainty within the literature. Identification of the context where surgical treatment intensity at the EoL is potentially inappropriate is not currently possible.