An analysis of interviews conducted with gynecologic oncologists revealed multiple concerns, including the possibility of care fragmentation, related to the introduction of a separate palliative care team at the time a malignant bowel obstruction is diagnosed. These findings were reported in JCO Oncology Practice.1
The diagnosis of malignant bowel obstruction, a major complication of certain advanced gynecologic cancers that is difficult to address, frequently represents a harbinger of poor prognosis.Integration of a palliative care team at this juncture is common given the high symptom burden of malignant bowel obstruction, including an inability to eat, in an already vulnerable group of patients.2
This study evaluated the perceptions and experiences of gynecologic oncologists regarding factors favoring involvement of a palliative care team at the time a malignant bowel obstruction is diagnosed in their patients, as well as barriers to this approach. Semistructured interviews were conducted with participating gynecologic oncologists affiliated with academic institutions, and transcripts of interviews were analyzed for thematic content.
Interviews were conducted with 15 of the 27 gynecologic oncologists invited to participate in the study. Approximately two-thirds of participants reported practicing at academic sites and the remainder reported practicing at academic/community sites. Most respondents had been in practice for less than 15 years.
Although all 15 gynecologic oncologists had previously consulted with palliative care, and had access to palliative care teams for their inpatients, none reported following specific protocols related to the involvement of palliative care at the time a malignant bowel obstruction was diagnosed.
Regarding whether they consulted palliative care at this milestone event, responses were fairly evenly divided between “always,” “frequently,” and “selectively,” with one respondent indicating “rarely.” Of note, nearly half of participating gynecologic oncologists favored earlier involvement of palliative care, prior to diagnosis of an acute event such as malignant bowel obstruction.
Most study participants generally expected to remain the primary clinical decision maker across all areas of patient management, including symptom control, discussions related to goals of care, and provision of psychosocial support, with a palliative care consultation serving the purpose of providing only those specific skills lacked by the primary provider. Some respondents expressed a fear that patients might feel a sense of abandonment if management of any of these areas of patient care were turned over to the palliative care team. Conversely, others were in favor of palliative team member involvement across all aspects of patient care.
Barriers to the provision of palliative care for these patients that were mentioned by some of the study participants included potential palliative care access limitations for outpatients, and the complexity of surgical decision making, with respondents more likely to seek a palliative care consultation in the setting of a patient with a nonsurgically managed malignant bowel obstruction.
Some limitations of this study included the small sample size and the uniform affiliation of study participants with academic medical centers, the study authors reported.
“More qualitative and quantitative research from the points of view of oncology teams, palliative care teams, and patients is needed around the integration of palliative care into gynecologic oncologic care, particularly surrounding engaging palliative care teams in a surgical subspecialty,” the authors concluded.
1. Hoppenot C, Hlubocky FJ, Chor J, Yamada SD, Lee NK. Approach to palliative care consultation for patients with malignant bowel obstruction in gynecologic oncology: a qualitative analysis of physician perspectives [published online April 2, 2020]. JCO Oncol Pract. doi: 10.1200/JOP.19.00710
2. Hoppenot C, Peters P, Cowan M, et al. Malignant bowel obstruction due to uterine or ovarian cancer: are there differences in outcome?Gynecol Oncol. 2019;154(1):177-182.