New paradigms of cancer and new language: A qualitative study exploring language around goals of cancer surgery.

Abstract

12099 Background: Cancer interventions are often discussed amongst providers and presented to patients within the dichotomy of “curative” vs. “palliative” interventions. However, as understanding of cancer biology has shifted and as cancer treatments have evolved, some cancers have become chronic diseases for which surgery may have a non-curative but disease-targeted role. Despite new paradigms of cancer care, language has not evolved to reflect new goals of cancer surgery. Methods: Semi-structured interviews were conducted with cancer surgeons from throughout the U.S. via purposive and snowball sampling. Interviews included discussions of two hypothetical scenarios describing non-curative surgical operations and discussion of the term “disease-controlling” surgery as a category of neither palliative nor curative surgical intent. Transcribed and de-identified interviews were analyzed inductively using grounded theory. Results: 18 surgeons from 16 institutions were interviewed. Surgeons collectively outlined how changes in the paradigm of cancer treatment have resulted in challenges describing intent of cancer surgery. Specifically, responses to the term “disease controlling” surgery elicited examples of cancer pathologies and treatment courses which fail to fit existing treatment-intent language and which captured new roles for surgery in cancer treatment paradigms. These roles of surgery include "surgery as curative treatment" (including both curative intent with probability of cure and curative intent with possibility of cure), "surgery as adjuvant treatment" (targeted surgery to assist systemic therapies with possible change in disease course), and "surgery as palliative treatment" (symptom relief surgery without possible change in disease course). Within the 'targeted surgery' category, participants described expanded surgical roles for numerous metastatic diseases including debulking for improved systemic therapy efficacy, resection of treatment-resistant disease sites, and "resetting the clock" for indolent tumors. These operations require multidisciplinary coordination and understanding of available systemic treatments, as surgical goals are increasingly defined by each patient's broader treatment trajectory. Conclusions: Traditional “curative” vs. “palliative” surgical intent categories inadequately describe contemporary cancer surgery. The emergence of life-extending but non-curative treatments necessitates new language frameworks that better align with current understandings of cancer biology and new treatment modalities. New language is necessary to facilitate clearer communication between providers and patients about surgical goals and expected outcomes and to allow for better research evaluating whether surgical treatments achieve those goals and outcomes.