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Patient Perceptions Regarding the Likelihood of Cure After Surgical Resection of Lung and Colorectal Cancer
Associated Data
Abstract
BACKGROUND
The objective of the current study was to characterize the prevalence of the expectation that surgical resection of lung or colorectal cancer might be curative. The authors sought to assess patient-level, tumor-level, and communication-level factors associated with the perception of cure.
METHODS
Between 2003 and 2005, a total of 3954 patients who underwent cancer-directed surgery for lung (30.3%) or colorectal (69.7%) cancer were identified from a population-based and health system-based survey of participants from multiple US regions.
RESULTS
Approximately 80.0% of patients with lung cancer and 89.7% of those with colorectal cancer responded that surgery would cure their cancer. Even 57.4% and 79.8% of patients with stage IV lung and colorectal cancer, respectively, believed surgery was likely to be curative. On multivariable analyses, the odds ratio (OR) of the perception of curative intent was found to be higher among patients with colorectal versus lung cancer (OR, 2.27). Patients who were female, with an advanced tumor stage, unmarried, and having a higher number of comorbidities were less likely to believe that surgery would cure their cancer; educational level, physical function, and insurance status were not found to be associated with perception of cure. Patients who reported optimal physician communication scores (reference score, 0–80; score of 80–100 [OR, 1.40] and score of 100 [OR, 1.89]) and a shared role in decision-making with their physician (OR, 1.16) or family (OR, 1.17) had a higher odds of perceiving surgery would be curative, whereas patients who reported physician-controlled (OR, 0.56) or family-controlled (OR, 0.72) decision-making were less likely to believe surgery would provide a cure.
CONCLUSIONS
Greater focus on patient-physician engagement, communication, and barriers to discussing goals of care with patients who are diagnosed with cancer is needed.
INTRODUCTION
Approximately 1.6 million new cancer cases and 589,430 cancer deaths are projected to occur in the United States in 2015.1 The burdens of lung and colorectal cancer are particularly high because these diseases constitute the 2 leading causes of cancer deaths in the United States.1 Despite advances in diagnostic and surgical techniques, the prognosis for patients with lung and colorectal cancer can be varied, with a subset of patients experiencing a high incidence of disease recurrence and cancer-specific death.2–6 Although overall 5-year survival rates for patients with lung and colorectal cancer are approximately 20% and 65%, respectively, the 5-year survival rates are reported to be only 4% and 30%, respectively, for patients with metastatic disease.1,7 For many patients with lung and colorectal cancer, surgery remains the treatment modality that confers the best chance of cure. In addition, for patients with symptomatic disease, surgery may provide symptom relief and improve quality of life.8,9
When considering treatment options, one of the most important discussions between patients with cancer and their health care providers involves the goal of any proposed therapy.10
Goals of care may involve whether the objective of the proposed therapy is to alleviate symptoms, prolong life, or provide a reasonable chance at “true cure.” Recent data have suggested that many patients with cancer do not understand the intent of certain therapies used to treat their cancer.11,12 Specifically, Weeks et al noted that >7 in 10 patients diagnosed with incurable metastatic lung or colorectal cancer reported the belief that systemic chemotherapy would cure them of their disease.11 Other studies have similarly suggested that patients diagnosed with cancer may not necessarily have an accurate perception of their prognosis, or the that cancer-directed treatments will be curative versus palliative.12
Although establishing “goals of care” is critical when considering any therapeutic intervention, these discussions are particularly relevant to surgery. Surgery has great potential to alleviate symptoms, as well as to extirpate disease in the hopes of obtaining long-term cure. However, surgery can also be associated with morbidity, mortality, worsening of quality of life, and considerable health care expense.13–15 As such, the lack of information regarding patient perception of the likelihood of cure after surgery is an important deficit in the literature. Therefore, the purpose of the current study was to characterize the prevalence of the expectation that surgical resection of lung or colorectal cancer might be curative. Specifically, using data from a national, prospective, observational cohort study, we sought to identify sociodemographic, clinical, and decision-making/communication factors that were associated with patient perception regarding the likelihood of cure after surgery for lung or colorectal cancer.
MATERIALS AND METHODS
Data Source
Data from the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS), a prospectively conducted cohort study designed to evaluate care and outcomes among patients with lung and colorectal cancer, were analyzed. The study enrolled approximately 5000 patients with either lung or colorectal cancer from 5 geographically defined regions (Alabama, Iowa, Los Angeles County, Northern California, and North Carolina), and from 15 Veterans Health Administration hospitals and 5 integrated health care delivery systems in the Cancer Research Network.16,17 Participants in the CanCORS study were identified within 3 months of diagnosis from population-based cancer registries; patients or a surrogate were interviewed by mail within 4 to 6 months of diagnosis regarding beliefs, goals of care, treatment decision-making process, and quality of life.18 Additional demographic information was obtained from participants via survey questions and information concerning cancer stage was collected from pathologic reports, radiology, and the medical records.19 The CanCORS study protocol was approved by the Institutional Review Boards at all sites and at the statistical coordinating center at the Dana-Farber Cancer Institute in Boston.17 The overall response rate was 49.1% for patients with lung cancer and 53.2% for patients with colorectal cancer.17
Cohort Selection and Data Collection
Patients eligible for enrollment in the CanCORS study were aged ≥21 years with a histologically or cytologically confirmed lung or colorectal cancer diagnosed between September 2003 and December 2005. For this study, we analyzed a subset of CanCORS participants who underwent cancer-directed surgery, as indicated by the participant responding “yes” to having undergone surgery for lung or colorectal cancer. Patients were excluded due to failure to respond to questions regarding expected effects of surgery (791 patients), surgery having not been completed at the time of the survey (597 patients), or missing information regarding cancer stage (419 patients).
Age at diagnosis, sex, race, marital status, education, income, insurance status, participation in an integrated health care network, number of comorbidities, physical function, and cancer stage were collected from the CanCORS data. We considered patients who were widowed, divorced, separated, and never married as unmarried. Patients were classified as having 0, 1, 2, or ≥3 comorbid conditions based on self-reported health history such as heart attack, stroke, congestive heart failure, diabetes, peripheral vascular diseases, chronic lung disease, diabetes, and chronic kidney disease.20 Physical function was categorized using 3 CanCORS survey items derived from the European Quality of Life-5 Dimensions (EQ-5D) questionnaire that identified problems with mobility, self-care, and usual activities. A patient was considered to have either good physical function if he/she responded “no” to all 3 of these items or poor physical function if the individual responded “yes” to ≥1 items.11,21 The TNM staging system was used to classify tumor stage at the time of diagnosis based on pathologic reports, radiology, and physician notes.19 Cases were grouped as stage I/II (localized), stage III (locoregional), or stage IV (metastatic) disease. The patient’s role in decision-making, patient-physician communication, and patient perceptions regarding potential beneficial and adverse effects of surgical treatment were derived from CanCORS survey questions and categorized as previously described (see Supporting Information Table 1).11,22,23 Satisfaction with physician communication was calculated from 5 survey items that were derived from the Consumer Assessment of Healthcare Providers and Systems (CAHPS), with an indication of 0 as the worst possible communication and 100 as optimal communication.11,18
Statistical Analysis
Categorical variables were presented as frequencies and percentages and compared using the chi-square test. Self-reported perception regarding the likelihood of cure was analyzed according to demographic, clinical, socioeconomic, and health system factors for each cancer type. Factors associated with the perceived likelihood of cure from surgery were analyzed using multivariable logistic regression and expressed as odds ratios (OR) and 95% confidence intervals (95% CIs). All variables of clinical interest were evaluated and those found to be statistically significant (P <.05) on bivariate analysis were included in multivariable analyses. To examine factors that were associated with the perception of cure, patients responding “very likely” or “somewhat likely” were categorized as perceiving surgical cure to be “likely.” Individuals who responded “a little likely,” “not at all likely,” or “I don’t know” were considered as perceiving surgery as “unlikely” to be curative.11,24 Raw, unimputed values were used to display descriptive data, whereas multiple imputation was used in multivariable analyses. All analyses were performed using Stata statistical software (version 12.1; StataCorp LP, College Station, Tex); a 2-tailed P value <.05 was considered to be statistically significant.
RESULTS
A total of 3954 patients who underwent cancer-directed surgery for either lung (1199 patients; 30.3%) or colorectal (2755 patients; 69.7%) cancer were included in the study cohort. The demographic and tumor characteristics of the study population stratified by cancer type are summarized in Supporting Information Table 2. The majority of patients had early-stage (stage I/II) (2435 patients; 61.6%) disease, whereas a subset of patients had either stage III (1023 patients; 25.9%) or stage IV (496 patients; 12.5%) disease. More patients with lung cancer presented with early-stage disease (72.1% with stage I/II, 18.3% with stage III, and 9.6% with stage IV disease) compared with patients with colorectal cancer (57.0% with stage I/II, 29.2% with stage III, and 13.8% with stage IV disease) (P<.001). Approximately 50% of the patients were aged >65 years (2047 patients; 51.8%) and most were white (2736 patients; 69.2%). A majority of patients were married or living with a partner (2485 patients; 62.9%) and approximately one-fourth had ≥a college degree (1065 patients; 27.0%). Approximately 97% of patients (3848 patients) had some type of insurance, with most participating in private insurance only (1497 patients; 37.9%) or Medicare plus private insurance (1319 patients; 33.4%). Before surgery, approximately one-half of patients reported good physical function (1794 patients; 45.4%) whereas the majority of patients reported at least 1 comorbid condition (2548 patients; 64.4%).
Perception of Cure With Surgery for Lung or Colorectal Cancer
Overall, 80% of patients with lung cancer (959 patients) and 89.6% of patients with colorectal cancer (2470 patients) perceived that surgery was likely to cure their cancer (Fig. 1A). Perception of cure was found to correspond with disease stage (Figs. 1B–1D). Specifically, 89.4% of patients with stage I/II disease (737 patients with lung cancer [85.2%] vs 1439 patients with colorectal cancer [91.7%]) noted that surgery was likely to cure their cancer, compared with 86.3% of patients with stage III disease (156 patients with lung cancer [71.2%] vs 727 patients with colorectal cancer [90.5%]) (both P<.05). Among patients with stage IV disease, 57.4% of patients with metastatic lung cancer (66 patients) and 79.8% of patients with metastatic colorectal cancer (304 patients) reported that surgery was likely to be curative.
Responses to questions regarding the likelihood that surgery would cure cancer among (A) the study population, (B) patients with lung cancer, or (C) patients with colorectal cancer stratified by tumor stage (TNM stage I/II vs stage III vs stage IV), and (D) patients with metastatic cancer.
On univariable analyses, factors such as female sex (OR, 0.82; 95% CI, 0.76–0.88), age ≥75 years (OR, 0.84; 95% CI, 0.75–0.94), marital status (OR, 0.75; 95% CI, 0.70–0.81), and insurance status (OR, 0.74; 95% CI, 0.56–0.97) were found to be associated with a lower likelihood of patient perception that surgery might cure their cancer (all P<.05). In contrast, nonwhite race (Hispanic [OR, 1.22; 95% CI, 1.05–1.42], African American [OR, 1.67; 95% CI, 1.46–1.90], or Asian American [OR, 5.37; 95% CI, 3.84–7.51]), higher income level (≥$60,000 [OR, 1.24; 95% 1.11–1.38]), and higher level of education (≥college degree [OR, 1.20; 95% CI, 1.06–1.35]) were each associated with a greater likelihood of patient perception that surgery would cure their cancer (all P<.05) (Table 1). Perception of likelihood of cure was higher among patients with colorectal cancer compared with those with lung cancer (OR, 2.17; 95% CI, 2.01–2.34 [P<.001]). This difference in perception of cure was noted across nearly all sociodemographic and cancer stage subgroups, except among Asian patients, whose perception of a likelihood of cure was comparable for lung (97.6%) and colorectal (96.8%) cancer (Table 2).
TABLE 1
ORs for the Association Between Various Demographic, Tumor, and Socioeconomic Factors and a Response to Questions About the Likelihood of Cure With Surgery
| Univariable | Multivariable | |||
|---|---|---|---|---|
| OR (95% CI) | P | OR (95% CI) | P | |
| Cancer type | ||||
| Lung | Reference | Reference | ||
| Colorectal | 2.17 (2.01–2.34) | <.001 | 2.27 (2.08–2.48) | <.001 |
| TNM stage of disease | ||||
| I or II | Reference | Reference | ||
| III | 0.75 (0.69–0.82) | <.001 | 0.66 (0.60–0.73) | <.001 |
| IV | 0.35 (0.32–0.39) | <.001 | 0.28 (0.25–0.32) | <.001 |
| Age, y | ||||
| 21–54 | Reference | Reference | ||
| 55–64 | 1.02 (0.91–1.14) | .75 | 1.06 (0.93–1.20) | .39 |
| 65–74 | 0.87 (0.79–0.97) | .14 | 0.92 (0.81–1.04) | .19 |
| ≥75 | 0.84 (0.75–0.94) | .002 | 0.88 (0.77–1.00) | .05 |
| Sex | ||||
| Male | Reference | Reference | ||
| Female | 0.82 (0.76–0.88) | <.001 | 0.79 (0.72–0.86) | <.001 |
| Race | ||||
| White | Reference | Reference | ||
| Hispanic or Latino | 1.22 (1.05–1.42) | .01 | 1.05 (0.88–1.25) | .58 |
| African American | 1.67 (1.46–1.90) | <.001 | 1.69 (1.45–1.97) | <.001 |
| Asian American | 5.37 (3.84–7.51) | <.001 | 7.66 (5.06–11.60) | <.001 |
| Other | 0.70 (0.60–0.81) | <.001 | 0.65 (0.55–0.76) | <.001 |
| Marital status | ||||
| Married or living with a partner | Reference | Reference | ||
| Unmarried | 0.75 (0.70–0.81) | <.001 | 0.78 (0.71–0.86) | <.001 |
| Education | ||||
| <High school diploma | Reference | Reference | ||
| High school degree or some college | 1.04 (0.94–1.15) | .45 | 1.04 (0.92–1.18) | .48 |
| ≥College degree | 1.20 (1.06–1.35) | .003 | 1.02 (0.88–1.18) | .80 |
| Income | ||||
| <$20,000 | Reference | Reference | ||
| $20,000–$40,000 | 0.90 (0.81–0.99) | .03 | 0.78 (0.69–0.87) | <.001 |
| $40,000–$60,000 | 1.19 (1.05–1.34) | .01 | 0.93 (0.81–1.07) | .34 |
| ≥$60,000 | 1.24 (1.11–1.38) | <.001 | 0.87 (0.76–1.01) | .07 |
| Good physical function | ||||
| Yes | Reference | Reference | ||
| No | 0.61 (0.59–0.64) | <.001 | 0.95 (0.87–1.04) | .25 |
| No. of self-reported comorbid conditions | ||||
| 0 | Reference | Reference | ||
| 1 | 0.76 (0.69–0.83) | <.001 | 0.86 (0.77–0.95) | .01 |
| 2 | 0.62 (0.56–0.69) | <.001 | 0.83 (0.73–0.93) | .002 |
| ≥3 | 0.58 (0.51–0.65) | <.001 | 0.78 (0.68–0.90) | .001 |
| Insurance | ||||
| No | Reference | Reference | ||
| Yes | 0.74 (0.56–0.97) | .03 | 1.10 (0.81–1.50) | .54 |
| Integrated health care network | ||||
| No | Reference | Reference | ||
| Yes | 0.82 (0.76–0.89) | <.001 | 0.82 (0.74–0.90) | <.001 |
| Patient-physician role in decision-making | ||||
| Patient-controlled | Reference | Reference | ||
| Shared control | 1.19 (1.09–1.30) | <.001 | 1.16 (1.06–1.28) | .002 |
| Physician-controlled | 0.55 (0.50–0.61) | <.001 | 0.56 (0.50–0.63) | <.001 |
| Patient-family role in decision-making | ||||
| Patient-controlled | Reference | Reference | ||
| Shared control | 1.22 (1.13–1.32) | <.001 | 1.17 (1.07–1.27) | .001 |
| Family-controlled | 0.55 (0.43–0.70) | <.001 | 0.72 (0.54–0.95) | .02 |
| Physician communication score | ||||
| 0–80 | Reference | Reference | ||
| 80–100 | 1.45 (1.31–1.61) | <.001 | 1.40 (1.24–1.57) | <.001 |
| 100 | 2.06 (1.87–2.27) | <.001 | 1.89 (1.70–2.11) | <.001 |
Abbreviations: 95% CI, 95% confidence interval; OR, odds ratio.
TABLE 2
Percentage of Patients Who Responded That Surgery Might Be Very Likely or Somewhat Likely Curative Stratified by Cancer Type
| Characteristic | Lung Cancer (n = 1199) | Colorectal Cancer (n = 2755) | Total (n = 3954) |
|---|---|---|---|
| Age, y | |||
| 21–54 | 131 (78.9) | 637 (89.6) | 768 (87.6) |
| 55–64 | 271 (81.1) | 633 (90.9) | 904 (87.8) |
| 65–74 | 330 (78.2) | 650 (90.7) | 980 (86.0) |
| ≥75 | 227 (81.9) | 550 (87.2) | 777 (85.6) |
| Sex | |||
| Male | 501 (80.9) | 1351 (90.7) | 1852 (87.8) |
| Female | 458 (79.0) | 1119 (88.5) | 1577 (85.5) |
| Race | |||
| White | 730 (79.8) | 1611 (88.5) | 2341 (85.6) |
| Hispanic or Latino | 42 (77.8) | 211 (90.2) | 253 (87.8) |
| African American | 97 (80.8) | 377 (93.8) | 474 (90.8) |
| Asian American | 40 (97.6) | 151 (96.8) | 197 (96.9) |
| Other | 50 (72.5) | 120 (84.5) | 170 (80.6) |
| TNM stage of disease | |||
| I or II | 737 (85.2) | 1439 (91.7) | 2176 (89.4) |
| III | 156 (71.2) | 727 (90.4) | 883 (86.3) |
| IV | 66 (57.4) | 304 (79.8) | 370 (74.6) |
| Marital status (n = 3950) | |||
| Married or living with a partner | 597 (80.7) | 1589 (91.1) | 2186 (88.0) |
| Unmarried | 361 (79.0) | 879 (87.2) | 1240 (84.6) |
| Education (n = 3947) | |||
| <High school diploma | 145 (73.6) | 398 (91.5) | 543 (85.9) |
| High school degree or some college | 588 (81.1) | 1356 (88.9) | 1944 (86.4) |
| ≥College degree | 222 (81.9) | 715 (90.1) | 937 (88.0) |
| Income | |||
| <$20,000 | 262 (79.2) | 623 (90.2) | 885 (86.6) |
| $20,000–$40,000 | 250 (79.1) | 677 (87.8) | 927 (85.3) |
| $40,000–$60,000 | 164 (84.1) | 458 (90.2) | 622 (88.5) |
| ≥$60,000 | 204 (82.3) | 678 (91.1) | 882 (88.9) |
| Integrated health care network | |||
| No | 720 (81.3) | 1896 (89.8) | 2616 (87.3) |
| Yes | 239 (76.4) | 574 (89.1) | 813 (84.9) |
| Good physical function (n = 3935) | |||
| No | 581 (78.2) | 1236 (88.4) | 1817 (84.9) |
| Yes | 373 (83.3) | 1224 (90.9) | 1597 (89.0) |
| No. of self-reported comorbid conditions | |||
| 0 | 249 (83.3) | 1006 (90.9) | 1255 (89.3) |
| 1 | 323 (80.3) | 826 (89.4) | 1149 (86.6) |
| 2 | 212 (78.2) | 406 (87.9) | 618 (84.3) |
| ≥3 | 175 (77.1) | 232 (88.5) | 407 (83.2) |
| Insurance | |||
| No | 15 (75.0) | 77 (89.5) | 92 (86.8) |
| Yes | 944 (80.1) | 2393 (89.7) | 3337 (86.7) |
| Patient-physician role in decision-making (n = 3931) | |||
| Patient-controlled | 423 (82.3) | 964 (89.6) | 1387 (87.2) |
| Shared control | 444 (81.9) | 1178 (92.1) | 1622 (89.1) |
| Physician-controlled | 84 (66.1) | 327 (83.2) | 411 (79.0) |
| Patient-family role in decision-making (n = 3884) | |||
| Patient-controlled | 481 (80.2) | 1215 (88.6) | 1696 (86.0) |
| Shared control | 449 (80.6) | 1180 (91.5) | 1629 (88.2) |
| Family-controlled | 14 (73.7) | 37 (78.7) | 51 (77.3) |
| Physician communication score (n = 3947) | |||
| 0–80 | 157 (71.7) | 377 (84.3) | 534 (80.2) |
| 80–100 | 256 (79.7) | 672 (87.8) | 928 (85.5) |
| 100 | 546 (82.8) | 1414 (92.1) | 1960 (89.3) |
The influence of sociodemographic, clinical, and communication factors on the perception of the likelihood of surgical cure was then examined using multivariable analyses (Table 1). Patients who were female (OR, 0.79; 95% CI, 0.72–0.86 [P<.001]) or unmarried (OR, 0.78; 95% CI, 0.71–0.86 [P<.001]) were less likely to perceive that surgery would provide a cure. In contrast, African American (OR, 1.69; 95% CI, 1.45–1.97 [P<.001]) and Asian American (OR, 7.66; 95% CI, 5.06–11.60 [P<.001]) patients were more likely to perceive that surgery would be curative compared with white patients; education and income levels were not found to be associated with perception of surgical cure (both P>.05) (Table 2). In addition, although patients with more preoperative comorbidities tended to be less likely to perceive cure (≥3 comorbidities: OR, 0.78; 95% CI, 0.78–0.90 [P<.001]), there was no difference noted according to self-reported poor preoperative physical function (OR, 0.95; 95% CI, 0.87–1.04 [P 5.25]). Perhaps as expected, the OR of a patient perceiving surgery as likely to be curative was found to be lower among patients with metastatic disease (OR, 0.28; 95% CI, 0.25–0.32 [P<.001]) versus patients with stage I/II cancer. After controlling for disease stage, patients with colorectal cancer were at a higher odds of perceiving surgery as likely to be curative compared with patients who had lung cancer (OR, 2.27; 95% CI, 2.08–2.48 [P<.001]).
Impact of Physician Communication and Decision-Making on Patient Perception of Cure
Based on the communication rating measure, approximately one-half of patients (2195 patients; 55.6%) rated communication with their physician as “optimal;” 40.4% and 13.2% of patients, respectively, reported patient-centered versus physician-centered control in decision-making (Supporting Information Table 2). On both univariable and multivariable analyses, communication and nidus of decision-making were associated with patient perception that surgery was likely to be curative. Specifically, on multivariable analysis after controlling for other factors, patients who rated patient-physician communication as optimal were more likely to perceive their surgery as likely to be curative compared with patients who reported the lowest communication scores (OR, 1.89; 95% CI, 1.70–2.11 [P<.001]). In contrast, patients who reported a noncontrolling role in treatment decision-making (ie, “physician made the decision”) were less likely to perceive surgery was curative when compared with patients who had a shared decision-making experience with their physician or family (OR, 0.56; 95% CI, 0.50–0.63 [P<.001]).
Patient-Reported Expectations About Surgery for Their Cancer: Life Extension, Symptom Relief, and Complications
Figure 2 details patient expectations regarding other beneficial and adverse effects of surgery including the likelihood that surgery would extend life, address cancer-related problems, or result in side effects or complications. Among patients with lung or colorectal cancer, 87.2% and 95.3%, respectively, reported that surgery was likely to prolong their life (Fig. 2A). Fewer patients reported a belief that surgery was likely to help manage problems related to their cancer. Overall, 50.2% of patients with lung cancer and 74.8% of patients with colorectal cancer (Fig. 2C) reported that surgery would likely help to manage cancer-related problems; this percentage was slightly higher among patients with stage IV metastatic lung (58.3%) or colorectal (83.7%) cancer (Fig. 2D). Overall, fewer patients reported that surgery would likely be accompanied by side effects or complications (44.6% of patients with lung cancer vs 45.0% of patients with colorectal cancer) (Fig. 2E). These percentages were even lower among patients with advanced-stage disease (30.4% for patients with stage IV lung cancer vs 43.8% of patients with stage IV colorectal cancer) (Fig. 2F).
Responses to questions regarding the likelihood that surgery would help patients survive longer among (A) the study cohort and (B) patients with metastatic cancer, that surgery would help patients with problems they were having because of cancer among (C) the study cohort and (D) patients with metastatic cancer, and that surgery would have side effects or complications among (E) the study cohort and (F) patients with metastatic cancer.
DISCUSSION
Patient expectations and perceptions regarding cancer therapy can be varied. Several previous studies have demonstrated that patients may misunderstand and overestimate the beneficial effects of nonsurgical therapy such as chemotherapy or radiotherapy.11,24 To our knowledge, no previous study has examined patient expectations regarding the effectiveness of surgical therapy among patients with cancer. The current study is important because it used a large, national, population-based cohort of patients to define the prevalence of perceptions that surgery would be curative for 2 of the most common cancers in the United States. It is interesting to note our observation that the belief that surgery would be curative among patients with lung or colorectal cancer was extremely widespread (>80%) and remained high (approximately 60%–80%) even among patients with metastatic stage IV disease. Furthermore, sociodemographic factors such as sex and race were associated with expectations, with female and white patients less likely to perceive that surgery for colon or lung cancer would provide a cure. In addition, a patient’s perceived role in decision-making, and self-reported quality of communication with their physician, impacted the odds of their perceiving surgery as likely to be curative.
In a clinical setting, patients with cancers with a particularly poor prognosis or symptomatic patients with advanced incurable disease may be subject to misunderstanding with regard to whether a recommended surgery is palliative or curative in intent.10 Weeks et al reported that 69% of patients with metastatic lung cancer and 81% of those with metastatic colorectal cancer had an inaccurate understanding that chemotherapy could cure their disease.11 In a separate study, Chen et al noted that the majority of patients receiving radiotherapy for lung cancer did not understand that it was not at all likely to cure their disease.24 In the current study, we expanded on this previous work and found that >80% of patients with lung or colorectal cancer believed that surgery was likely to cure their cancer. Of particular interest was the finding that even among patients with stage IV lung or colorectal cancer, approximately 60% to 80% of patients reported that surgery was likely to be curative. However, several studies have reported that actual cure even among well-selected patients who undergo curative-intent resection of stage IV colorectal cancer is only approximately 10% to 15%.25–28 Similarly, the chance of “cure” among patients undergoing surgical resection of stage IV lung cancer is similar or even lower.29,30 In light of established prognostic information, data from the current study suggest that there are patient misperceptions regarding the benefits and prognosis associated with surgery. The reasons for these misperceptions are undoubtedly multifaceted and likely involve, to some degree, patient-physician communication.31–33
Discussions among patients and physicians are very important to ensure that accurate information is exchanged to facilitate comprehensive decisions regarding treatment and goals of care.10 Previous studies have demonstrated the importance of quality patient-physician communication to help patients and family members make informed decisions, manage cancer effectively, and improve psychosocial health outcomes.12,34–40 It is interesting to note that we observed an increased perception of possible cure among patients who reported favorable communication, as well as among patients who reported shared decision-making, with their physician (Table 1). In contrast, patients who reported that the decision to undergo surgery was controlled by the physician were less likely to perceive the surgery as being potentially curative. These findings suggest that patients who are more engaged and satisfied with their provider in decision-making discussions regarding cancer-directed treatment may have an elevated perception of possible cure. It is interesting to note that although the overwhelming majority of patients perceived an anticipated benefit of surgery, considerably fewer expected any surgery-related complications. Specifically, >90% of patients responded that surgery was likely to prolong their life and approximately 70% believed their surgery would help cancer-related problems. In contrast, only approximately 40% of patients expected surgery to have any side effects or complications. Collectively, these data serve to emphasize how patients tend to heavily weight the risk-benefit ratio of surgery toward more favorable outcomes.
The current study has several limitations. We were unable to ascertain the intent of surgery for patients with lung or colorectal cancer. As such, some patients may have undergone surgery for palliative, rather than curative, intent. The number of patients who underwent a purely palliative surgery was most likely low; in addition, any inclusion of palliative surgical cases would make the findings of overestimation of “cure” in the current study even more pronounced. In addition, although the total number of patients in the CanCORS cohort was large, the number of patients with metastatic disease who underwent surgery was relatively small (approximately 500 patients), and thus may have inhibited our power to detect small differences in this subgroup.
The results of the current study demonstrate that the overwhelming majority of patients undergoing surgery for lung or colorectal cancer believe that the surgery is likely to be curative. Even among patients undergoing surgery for advanced stage IV disease, the belief that surgery would result in cure was widespread. Certain sociodemographic and decision-making/communication factors were found to be associated with the odds that a patient perceived surgery to be curative. Data from the current study provide insight into patient perceptions regarding the goals of surgery for lung and colorectal cancer and highlight how the majority of patients, even those with advanced disease, believe that surgery will result in a cure. Future studies should focus on more closely examining patient-surgeon engagement and communication, as well as barriers to discussing goals of care with patients undergoing cancer-directed surgery.
Acknowledgments
FUNDING SUPPORT
The work of the CanCORS consortium was supported by grants from the National Cancer Institute (NCI) to the Statistical Coordinating Center (U01 CA093344) and the NCI supported Primary Data Collection and Research Centers (Dana-Farber Cancer Institute/Cancer Research Network U01 CA093332, Harvard Medical School/Northern California Cancer Center U01 CA093324, RAND/UCLA U01 CA093348, University of Alabama at Birmingham U01 CA093329, University of Iowa U01 CA093339,University of North Carolina U01 CA 093326) and by a Department of Veteran’s Affairs grant to the Durham VA Medical Center VA HSRD CRS-02-164).
Footnotes
Additional Supporting Information may be found in the online version of this article.
CONFLICT OF INTEREST DISCLOSURES
The authors made no disclosures.