The timing and the dose of advanced care planning in patients with resectable pancreatic cancer: Who makes the call?
Authors: Demyan Lyudmyla , Wu Grace , Moumin Dina , Deutsch Gary B , Nealon William , Herman Joseph Michael , Weiss Matthew John , Burns Edith , Deperalta Danielle 
Published: January 2021

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Background:The timing and the extent of Advanced Care Planning (ACP) in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing curative-intent resection are generally dictated by the surgeon performing the operation. The aim of this study is to evaluate surgeons’ insights, perceptions, and biases regarding preoperative ACP. We hypothesize that many surgeons harbor significant reservations about extensive preoperative ACP. Methods:A qualitative investigation using 1:1 interviews with 40 open-ended questions were conducted with convenience sample. Data accrual continued until theme saturation was achieved. Grounded theory approach was used for data coding and analysis. Results:A total of 10 interviews were conducted with expert pancreatic surgeons from 6 medical centers—6 males and 4 females. The median number of years in practice was 15 (IQR 13-30) and the median number of pancreatic cancer cases performed per year was 52 (IQR 39-75). During preoperative counseling all surgeons discuss the possibility of recurrence and postoperative complications but attempt to motivate patients by emphasizing hope, optimism, and fact that surgery offers the only opportunity for cure. 90% of surgeons report no formal training in ACP. All surgeons report comfort with end of life conversations when death is imminent, but most lack experience with in-depth preoperative ACP. All surgeons emphasized that ACP should be led by a physician that both knows the patient well and understands the complexity of PDAC management. All surgeons recognized potential benefits of ACP, including delivery of goal-concordant care (60%), increased prognostic awareness (40%), and better life planning (40%). 50% report discussing in-depth ACP related to perioperative complications, but not long-term oncologic outcome. 80% of surgeons report that they actively steer away from in-depth ACP during preoperative counseling. Barriers to in-depth ACP reported by surgeons include taking away hope (70%), lack of time (50%) and concern for sending “mixed messages” (50%). Further, 50% of surgeons perceived that extensive preoperative ACP is not appropriate for patients with PDAC undergoing curative-intent resection. Most surgeons (60%) believe that ACP should occur as a process throughout the disease and in-depth discussions were more appropriate during postoperative visits (30%) and/or recurrence (60%). Conclusions:Despite recognizing potential benefits, most pancreatic surgeons report actively avoiding in-depth ACP conversations prior to curative-intent surgery. Surgeons had difficulty articulating the best time for ACP and felt that ACP should occur as a continuum throughout the course of treatment, with the depth of the discussion echoing the disease progression and patients’ readiness for such conversation. Future studies could evaluate patients’ perspective on the timing and the dose of ACP.