Optimized treatment of malignant intestinal obstruction in patients with advanced gynecologic cancer
Objective:
Malignant intestinal obstruction (MBO) is a common and distressing complication in patients with advanced gynecologic cancers. In 2016, a large tertiary cancer center in Canada launched an interspecialty MBO pilot program to integrate the complex care needs of these patients across multiple disciplines and support women with MBO.
Way:
A retrospective analysis was performed to evaluate the treatment outcomes of female patients with advanced gynecologic cancer admitted to the hospital for MBO before the MBO program (2014 to 2016: baseline group) and after the implementation (2016 to 2018).
Outcome:
Of the 169 women assessed, 106 were in the baseline group and 63 in the MBO program group. Most had ovarian cancer (n = 124; 73%) and small bowel obstruction (n = 131; 78%). The cumulative length of hospital stay (LOS sum) in the first 60 days after MBO diagnosis was significantly shorter in the MBO program group compared to the baseline group (13 v 22 days, respectively; adjusted P = .006). Median overall survival was also significantly longer in women treated with the MBO program compared to the baseline group (243 v 99 days, respectively; adjusted P = .002). Using the interprofessional MBO care platform, the proportion of patients receiving palliative chemotherapy (83% v 56%) and the proportion of surgery (11% v 21%) were higher in the MBO plan group than in the baseline group. A subset of women (n = 11) received full parenteral nutrition for more than 6 months.
Conclusion:
Implementing a comprehensive, interprofessional MBO program can significantly impact patient care and potentially improve treatment outcomes. This MBO program is unique in that it employs an integrated outpatient care and education model that enables patients to recognize MBO symptoms for early intervention.
introduce
Malignant intestinal obstruction (MBO) is a common symptom in patients with advanced gynecologic cancers, particularly ovarian cancer. Previous retrospective series have reported that up to 51% of women with recurrent ovarian cancer will develop MBO, with median survival after MBO diagnosis ranging from 45 to 169 days. The development of MBO is usually subacute and can progress to distressing symptoms such as inability to eat, vomiting, and abdominal cramps and bloating. Treatment with MBO usually requires a prolonged hospital stay. Despite the initial intervention, most of these women experience repeated episodes of MBO over time, which can negatively impact their quality of life. Although MBO is a common complication, there are no guidelines on how to treat MBO.
Management buyout pilot project
Optimal and effective management of MBO is an unmet clinical need. To address this complex clinical challenge, in June 2016, a large tertiary cancer center in Canada launched an MBO pilot program with an integrated outpatient care model. A dedicated multidisciplinary MBO team consists of medical, surgical, gynaecological and radiation oncologists, palliative care physicians, diagnostic and interventional radiologists, total parenteral nutritionists, specialist oncology nurses, dietitians, pharmacists and social workers. After reviewing the literature, the MBO Working Group developed the following: (1) an expert consensus MBO clinical care algorithm for both inpatients and outpatients; (2) patient education materials; (3) standardized tools for the classification and management of MBO symptoms; and (4) guidelines for participation in advanced care planning and palliative care (data supplement).
Patients suspected of having MBO are reviewed in a timely manner to establish a diagnosis, classified according to a standardized MBO assessment tool, and treated according to the Princess Margaret Cancer Center MBO algorithm (data supplementation) using the MBO program framework. The MBO assessment tool is a one-page questionnaire that focuses solely on bowel function, such as bowel frequency, stool consistency, nausea, vomiting, flatulence, abdominal pain, bloating, early satiety, fluid consumption, and medications taken (e.g., laxatives, opioid analgesics). Patients undergo additional radiological imaging tests depending on their symptoms. Once diagnosed with MBO, patients will immediately undergo MBO symptom management (i.e., bowel rest, parenteral rehydration, and medication management) and will be reviewed by a member of the MBO team to consider surgical intervention, chemotherapy, total parenteral nutrition (TPN), and optimal supportive care based on disease prognosis. Early discussions on goals of care and advanced care planning were included. Patient care is systematically recorded in electronic medical records to ensure effective communication within an interprofessional network.
Patients known to the MBO program were classified according to a color-coded system: (1) red indicated active MBO patients requiring hospitalization; (2) Orange indicates active MBO patients who are candidates for outpatient treatment; (3) yellow indicates patients who do not have MBO but are at risk of developing MBO; (4) green indicates patients with no intestinal symptoms suggestive of MBO; (5) Blue indicates patients with a diagnosis of active MBO whose primary treatment goal is comfort care by the palliative care team (data supplement). Patients deemed suitable for outpatient treatment (code orange and yellow) are actively followed by a dedicated oncology nurse through telephone consultations between outpatient appointments with their clinician (surgical, medical, or palliative care team). If the MBO resolves and the patient is asymptomatic for at least 1 month, switch to a different color code (yellow or green). As part of the MBO program, written patient education materials, including a booklet on "Learn How to Maintain Good Bowel Function" and low-residue dietary information, are provided to all patients.
All MBO cases are discussed at regular MBO multidisciplinary case meetings to review radiological images and consensus treatment recommendations. If the patient is deemed unsuitable for surgery, a treatment plan will be documented so that the medical oncology and palliative care team can work together.
way
Since June 2016, the Princess Margaret Cancer Centre has launched an interspecialty MBO pilot program with an integrated outpatient care model. A retrospective analysis was conducted to evaluate the effect of the MBO program on the cumulative length of stay (sum of LOS) for MBO management for all consecutive patients with intestinal obstruction (International Classification of Diseases, Tenth Revision, code: K56 or K91.3) between April 2014 and March 2018 (based on the fiscal year) at the Princess Margaret Cancer Centre and/or affiliated Toronto General Hospital. Patients were identified using data from the National Ambulatory Care Reporting System, which collected patient admissions, emergency department visits, and community outpatient care information. A chart review was performed to select MBO patients who met the following criteria: (1) clinical evidence of intestinal obstruction (medical history, physical examination, and radiological examination); (2) intestinal obstruction due to malignant deposits other than the ligament of Treitz; (3) Diagnosed with advanced gynecological cancer. These criteria are consistent with the definition of MBO developed by the International MBO Conference and the Clinical Protocols Committee. 8We excluded patients with MBO at the time of initial diagnosis of ovarian cancer, and patients with intestinal obstruction due to non-cancer-related causes such as adhesion incarcerated hernia, sigmoid volvulus, and radiation strictures.
For all eligible patients, a detailed chart review was performed and reviewed by at least two authors (YCL, KN, and SC). The following data fields were extracted and recorded: patient demographics, tumor characteristics (i.e., primary tumor site, histopathology, cancer stage, BRCA1/2 mutation status, presence of ascites), treatment history (i.e., date, type, and route of treatment), nutritional markers (i.e., albumin, height, weight), and MBO management and treatment outcomes. Patients with ovarian cancer receiving chemotherapy are classified as platinum-sensitive (more than 6 months) or platinum-resistant (6 months or less) based on prior treatment-free intervals at the time of MBO diagnosis.
Statistical analysis
The primary objective of this study is to compare the cumulative number of days of hospitalization in the first 60 days of diagnosis of MBO before and after the implementation of the MBO program. A general linear model was used to estimate differences between groups, controlling for age, histology, and platinum sensitivity status. Survival outcomes were compared using the Kaplan-Meier method and log-rank test and reviewed at the last follow-up visit in May 2018.
All P-values were bilateral, and P< .05 was considered statistically significant. The descriptive summary includes the mean and confidence intervals for quantitative measures and the number and percentage of cases for qualitative measures.
outcome
Based on the above selection criteria, a total of 312 patients were identified from hospital records. Of these, 143 patients were excluded for the following reasons: intestinal obstruction due to postoperative intestinal obstruction (n = 86), adhesions (n = 40), incarcerated hernia (n = 5), sigmoid volvulus (n = 3), radiation stricture (n = 2), and MBO (n = 7) at the time of initial diagnosis of ovarian cancer. The remaining 169 patients were divided into two groups for comparison: the baseline group (before the MBO program was implemented) and the MBO program group (after the MBO program was implemented).
discuss
To the best of our knowledge, this is the first study to demonstrate the benefit of an interprofessional MBO program in improving the complex care of patients with MBO secondary to gynecologic cancers. Patients treated in the MBO program are discharged more quickly than those who were treated before the MBO program and receive support as outpatients. In addition, they were more likely to receive multimodal interventions under a collaborative multidisciplinary care platform (MBO program vs. baseline, 43 versus 33 percent) and had a longer median survival of approximately five months.
In our study, the majority of women with MBO had recurrent ovarian cancer, and unfortunately, their MBO recurrence required ongoing treatment. This finding is consistent with the report by Martinez Castro et al. that women with MBO and ovarian cancer had a median of 3 episodes of MBO before death; The median time interval between each episode was 17 (range 1 to 727) days. In the above study, the mean LOS per episode of MBO was 13 days. In contrast, our study captured the cumulative sum of LOS over the first 60 to 180 days to include recurrent hospital admissions for each patient. The sum of LOS improved significantly from 22 days to 13 days (within the first 60 days after diagnosis of MBO), demonstrating the positive impact our MBO program has played in enhancing and sustaining high-quality care support in the outpatient clinic.
This MBO program is unique in that it adopts an integrated outpatient care model and emphasizes patient education. The MBO program leverages existing hospital resources and infrastructure to connect inpatient and outpatient care teams. Using a standardized classification and assessment tool we have developed, professional gynecologic oncology nurses actively track patients' symptoms for early intervention and support. The program also connects patients to community care services, such as home palliative care services, community outpatient care, and home care services, to maximize patient support at home without incurring additional costs to the hospital system. Education about MBO is also critical to enabling patients and their caregivers to confidently manage their symptoms and know when to seek help, especially given the high risk of MBO recurrence. Provide patients with a didactic and written information package about MBO so that they can effectively communicate their symptoms and participate in decision-making. This study shows how measures such as standardized proactive assessment and educational tools can be used to evolve the previous model of inpatient care into a sustainable, safe, and efficient model of outpatient care.
Survival was significantly longer by approximately 5 months in the MBO program group compared to the baseline group. Median OS in the baseline group was comparable to previously reported at 45 to 169 days. The clinical and MBO characteristics were similar in both groups. We hypothesize that this survival advantage is attributable to the overall impact of the MBO program in terms of early identification of symptoms, tailored therapeutic interventions (before complications appear), and optimal supportive care specifically for women with MBO secondary to gynecologic cancers. A core feature of the MBO program is that patient cases are reviewed at a dedicated MBO multidisciplinary case conference. This interdisciplinary approach may explain the differences in treatment patterns between the two groups and explain why patients in MBO programs are more likely to receive multimodal interventions. The integration of management algorithms simplifies the transition of patients from hospital to home. After discharge, a dedicated gynecologic oncology nurse and community service staff actively follow the patient. In addition, patients are screened and referred to relevant medical professionals such as dietitians for nutritional assessment and education on low-fiber diets. Together, all of these measures will provide early intervention for patients who already have or are at risk of developing another MBO.
There has been controversy regarding the use of TPN in patients with incurable cancer who have developed intestinal obstruction. Previous studies investigating TPN use in patients with advanced gynecologic cancer and MBO have invariably reported a shorter median OS time (40 to 93 days) and a complication rate of up to 54%, such as catheter-related infections. However, these studies also included a subset of patients with a longer survival time (24% survival at 6 months and 8% survival after 1 year). The predictors of who will benefit from long-term TPN remain unclear. Similarly, we found that 27% of patients treated with TPN appeared to have long-term benefits, surviving for more than 6 months and up to 2 years. Because our center offers at-home TPN services, patients deemed suitable for TPN will begin TPN in the hospital while receiving TPN self-management training prior to discharge. After discharge, they will be followed by a family TPN program and will be helped to self-administer TPN overnight at home. The catheter complication rate was 24% in patients receiving TPN, which may be due to frequent use of the central catheter over a long period of time.
Given the retrospective analysis of this single-institution study, there are limitations to this study. This pilot MBO program requires further validation to determine if it can be adopted by other institutions. The extensive integration of this MBO program will depend on the organization, infrastructure, and resources available to the local healthcare system. Given the inherent limitations of this retrospective study, it is not possible to distinguish between improved survival associated with leading time deviations (because MBO was identified early and survival was measured from earlier time points), or true survival improvement (because there are more opportunities for treatment and intervention based on identifying impending intestinal obstruction and managing it more effectively). Prospectively confirmed improvement in survival requires randomized assessment by cluster-randomized clinical trials. There is also ongoing debate about what constitutes a clinically relevant study endpoint for symptom control in MBO. The recurrent and progressive nature of MBO may inherently hinder the ability to appropriately assess the effectiveness of MBO interventions. A Prospective Clinical Trial (Risk Stratification of Malignant Intestinal Obstruction in Women With Advanced Gynecologic Cancer [MAMBO] Program Study; ClinicalTrials.gov Identifier: NCT03260647) is currently ongoing, and this trial integrates quality of life indicator assessments and qualitative interviews in MBO patients to assess their care needs.
In conclusion, a collaborative approach helps optimize care for MBO patients and improve patient outcomes. Implementing an interprofessional MBO program can reduce hospital stays and support and empower patients in an outpatient setting without adding additional financial or infrastructural strain to specialized cancer centers.
Optimizing the Care of Malignant Bowel Obstruction in Patients With Advanced Gynecologic Cancer - PubMed