“What’s a win”: A qualitative study exploring surgeon perspectives on operative intent in non-curative cancer surgery

INTRODUCTION

Over 600,000 individuals in the U.S. live with metastatic cancer of the six most common cancer types.¹ This estimate is expected to rise in the coming years due to improvements in cancer treatments, increased detection, and the aging population.¹ Therapeutic advances have increased survival by years for some patients with metastatic or incurable malignancies.^2,3 As more of these individuals live longer with their disease, surgeons will increasingly need to consider non-curative surgical interventions that are either symptom-directed (e.g. to reduce pain or other symptoms) or disease-directed (e.g. to prolong survival, prevent future disability, or allow respite from maintenance medical therapies). Clear descriptions of treatment intent can help ensure that patients and their families have realistic expectations about what surgery can and cannot achieve, thereby enabling patients to make informed decisions based on their values and priorities.^4–6

Although communicating treatment intent is important, the language used to describe operations performed on patients with incurable cancer falls short. The term “palliative surgery” suggests symptom-relieving interventions, and is therefore not applicable for patients who are asymptomatic. The term “cytoreductive surgery” describes tumor debulking, but requires familiarity with medical terminology. Furthermore, the ultimate benefit to patients remains murky: cytoreductive surgery could be performed to alleviate symptoms but it could also potentially prolong life.⁷ Prior research has shown that patients receiving chemotherapy for incurable cancer frequently do not understand the treatment intent of such palliative therapy.⁴ Ineffective communication impedes patient understanding of the goals of surgery for advanced cancer and therefore prevents patients from making fully informed decisions about their care.^8–13

Despite evidence of significant communication challenges, surgeons’ perspectives on and current preferences for discussing operative intent in non-curative cancer surgery are not known. To address this gap, we sought to explore the terminology that cancer surgeons favor when discussing the intent of non-curative operations as well as their communication priorities when weighing surgical options for patients living with incurable cancer.

METHODS

Participants, Sampling, and Recruitment

We purposively sampled surgeons who frequently perform cancer operations. Although subspecialty training in surgical oncology was not required, potential participants were identified through surgical oncology society memberships and subsequent snowball sampling. To capture diverse perspectives, participants were selected to vary in demographic factors and years of practice. Recruitment concluded upon reaching thematic saturation. The Mass General Brigham Institutional Review Board deemed this study exempt from review. Findings are reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.¹⁴

Data Collection

We collected demographic details of participants (Supplement A) and developed a semi-structured interview guide (Supplement B) comprised of two case scenarios involving patients seeking surgical consultation for intra-abdominal metastases from malignant melanoma – one symptomatic with disease progression on systemic therapy, the other asymptomatic with evidence of partial response to systemic therapy (Figure 1). Questions explored surgeons’ decision-making processes and communication choices for each case. Lastly, we introduced the term “disease-control surgery” – defined as “operations that may not cure a patient’s disease but can potentially let them live longer or prevent disability” – and solicited feedback on the utility of this or alternate terms. The interview guide was iteratively refined among study investigators and cognitively tested. Thereafter, two study investigators (O.F. and A.R.) conducted one-on-one interviews with participants either over video conferencing or in-person during a national conference in March of 2024. We obtained verbal consent from all participants to record interviews.

Figure 1. Case scenarios from semi-structured interview guide.

These two case scenarios were provided to participating surgeons who were then asked to reflect on their surgical decision-making processes. Additionally, surgeons either offered or were prompted to share how they would discuss the scenario with the involved patient. See Supplement A, Supplemental Digital Content 1, http://links.lww.com/SLA/F492 for full semi-structured interview guide.

Data Analysis

Interviews were professionally transcribed and deidentified. Data were analyzed using inductive thematic analysis. Study investigators developed a codebook through a series of meetings. One-third of transcripts were triple coded by three investigators (O.F., A.R., E.L.) and compared, and one investigator (O.F.) coded all remaining transcripts independently. Associations between codes were discussed, and themes were developed through regular team meetings. Data were managed and analyzed using Atlas.ti Software version 23.3.0.¹⁵

Study Team

The study team that conducted the interviews and coded the transcripts was comprised of a surgical resident and attending surgeon (O.F., E.L., respectively) with prior experiences in qualitative methods and a non-clinician qualitative research expert (A.R.). Interviewer-participant pairings were chosen such that that no prior relationships existed.

RESULTS

Participant Characteristics

Among 18 surgeons enrolled and interviewed, 7 (39%) were female and 8 (44.4%) were White (Table 1). Participants practiced at 16 different institutions with 3 (17%) at community hospitals and the remaining at academic centers. Eight participants (44%) had <10 years in practice while 2 (11%) had >20 years of experience. Surgeons’ operative practice varied with 8 (44%) treating hepatobiliary cancer, 5 (28%) peritoneal disease, and 6 (33%) gastric malignancy – among other cancer types.

Table 1. Participant characteristics.

Descriptive statistics of participating surgeon baseline demographic characteristics and surgical practices. Participants could select multiple options for institution type (e.g., National Cancer Institute cancer center and academic hospital) and for disease-focus, therefore, these values do not sum to the total number of participants. Missing data due to incomplete demographic survey.

	N = 18
Gender (Female), n (%)	7 (38.9%)
Ethnicity, n (%)
Hispanic	2 (11.1%)
Non-Hispanic	12 (66.7%)
Other	3 (16.7%)
Missing	1 (5.6%)
Race, n (%)
White	8 (44.4%)
Asian	3 (16.7%)
Black	2 (11.1%)
Other	4 (22.2%)
Missing	1 (5.6%)
Years of Practice, n (%)
<5 years	3 (16.7%)
5–10 years	5 (27.8%)
11–20 years	8 (44.4%)
>20 years	2 (11.1%)
Institution Type, n (%)
Academic	15 (83.3%)
Community	3 (16.7%)
NCI* Designated Cancer Center	3 (16.7%)
Disease-Focus, n (%)
Hepatopancreatobiliary	8 (44.4%)
Melanoma / Sarcoma	7 (38.9%)
Peritoneal Surface	5 (27.8%)
Gastric / Upper Gastrointestinal	6 (33.3%)
Endocrine	3 (16.7%)
Head and Neck	1 (5.6%)
Colorectal	1 (5.6%)
Other	1 (5.6%)

^*NCI = National Cancer Institute

How Do Surgeons Describe the Goals of Non-Curative Surgery?

Preferred Terminology

We explored surgeons’ preferred language for describing the aim of non-curative surgery, including our proposed term, “disease-control surgery.” While several participants embraced this term without reservations, most raised concerns. These concerns varied between participants – often, in opposing ways. Some felt that the term oversells the goals, believing that the idea of “control” is overly-optimistic for what surgery can achieve for patients with incurable cancers. Others thought that the term undersells the potential benefit of non-curative surgery as, sometimes, disease-targeted operations can prolong life.

Participants also posed many alternatives to “disease-control surgery,” including the terms disease-maintenance surgery or prophylactic, pre-, or expectant palliation. Additionally, many spoke of operations to reset the clock. Most frequently, participants described the overarching goal of non-curative surgery as preventing disease progression. For example, “[T]here are certainly cases where it may not be altering the treatment trajectory per se, but could potentially help prevent a progression. I don’t think I’m going to control disease, but I do think I could potentially prevent an obstruction or bleeding” (Participant #1). In this case, preventing progression aimed to stall future symptom development. However, this term was sufficiently comprehensive that it was often employed as a surrogate for either of the related, but more specific goals of enabling patients to live longer and/or live better.

Living Longer and Living Better

Surgeons often delineated the operative intent for patients with incurable cancers as living longer and/or living better. At least one of these goals was needed to ensure that non-curative operations are worthwhile to patients. Living longer could be achieved by (1) removing sites of disease that were refractory to treatment: “[T]he goal of this operation is to get rid of the disease that’s progressing and will probably will make them live longer” (Participant #3); or (2) managing or preventing life-limiting sequelae of advanced cancer: “So you could do this [surgery], and it helps people live better…But in doing so, you could very easily also make them live longer because now they’re no longer symptomatic. They’re no longer dying of their bowel obstruction. They’re no longer having issues that now are allowing them to get more therapy or chemo” (Participant #7). Participants acknowledged that living longer was not always achievable, may provide only modest survival benefit, and could lead to burdensome symptoms, recovery, and healthcare needs. Alternatively, the goal of surgery could be to help patients live better.

Living better encompasses a myriad of different outcomes, including palliation of current symptoms, improving quality of life, preventing future debility or symptoms, and avoiding undesired hospitalizations or treatments. These objectives could stand alone to help patients feel better or could potentially contribute to extending their survival as described. Operations that enable a patient to receive recommended medical therapies or render those therapies more effective, were sometimes considered life-prolonging, and other times, discussed within the framework of living better – potentially improving the symptoms of cancer. Overall, most surgeons framed the indications for non-curative surgery around these two distinct, but sometimes synergistic operative intents.

Non-Curative Surgery Involves Inherent Uncertainty

Although participants delineated the discrete goals of living longer and living better, they also emphasized their uncertainty around realistically achieving these goals. The participants identified various sources of uncertainty: the unpredictability of disease-process and prognosis, as well as data limitations regarding operative decisions and surgical outcomes. Such uncertainty was often expressed explicitly, e.g., “[W]e don’t know have the science behind it yet” (Participant #9). Other times, it was implied by shifting statements about possible benefits (e.g., “You know I make it clear that we don’t know what the actual benefit of surgery is…But then I say, you know there may be some benefit…” [Participant #18]) or by posing potential outcomes as questions rather than end-points (e.g., “[C]an I help you live longer relative to the disease? Can I help you with symptoms that you might develop…?” [Participant #13]) (Table 2). Evident in discussions of case scenarios, grappling with this uncertainty is central to the decision-making process for non-curative operations and informs how surgeons communicate the goals of surgery to patients with incurable malignancies.

Table 2. Representative quotations acknowledging the uncertainty inherent in decision-making around non-curative surgery.

Surgeons both explicitly stated and implicitly suggested high levels of uncertainty in non-curative cancer care. Implicit indicators included waffling between risks and benefits or posing potential outcomes as questions.

Explicit Statements of Uncertainty

Implicit Statements of Uncertainty

“[W]e’re operating in this gray area right now in melanoma in particular, as we’re still learning how to deal with metastatic melanoma and what the appropriate treatment paradigms are.” (Participant #1) “But we don’t have the science behind it yet. If I knew that this person wasn’t curative and they were going to recur in two years and die within three years and I could have an upfront conversation with them...” (Participant #9) “This is a data-free zone. We don’t know if we’re actually going to limit your disease progression…It’s a gamble.” (Participant #18) “[W]hen I propose to do surgery for patients of any kind with cancer, I never tell them, ‘Well, I’m going to cure you’ because chances are I’m not. And chances are, even if I think I am, I don’t know because it can still recur.” (Participant #11)

“Recognizing that surgery is not going to - almost certainly not going to [pauses], well, it depends. But I’m not operating for curative intent or necessarily even for longevity or length of life, but it would be for quality of life…Now, that said…there’s certainly a distinct possibility that they have complications…which could make them feel worse…” (Participant #1) “[C]an I help you live longer relative to the disease? Can I help you with symptoms that you might develop if it’s allowed to progress in that location?” (Participant #13) “I think we would tell the patient, ‘Look, I think this is curative intent. Let’s go in and take that last thing out. I can’t guarantee you that nothing will ever come back.’ With two lesions, it starts to become that borderline. Like are we offering curative resection? Are we offering reduction of morbidity?” (Participant #5)

As we further explored cancer surgeons’ perspectives on non-curative surgery, three themes emerged pertaining to their communication priorities: 1) Clarifying treatment intent, 2) Disclosing uncertainty, and 3) Establishing alignment.

What Do Surgeons Prioritize When Communicating Goals for Non-Curative Surgery?

Theme 1: Clarifying Treatment Intent

Participants favored explicitly discussing potential surgical risks and tradeoffs. But beyond these features, surgeons underscored the value of transparent communication with patients around operative intent, emphasizing that communicating clear intent is necessary to ensure accurate understanding of prognosis and to facilitate informed surgical decisions: “[H]aving that clarity is so incredibly important so that [patients] know how to align their goals of care with the reality of their situation” (Participant #16). Surgeons also acknowledged the role of medical oncologists in these discussions and the need for a shared understanding among members of the care team. One participant stated: “[T]hat’s important for the provider as well…You can’t have one member of the treatment team think that your surgery is going to somehow cure the patient if you realize that your surgery is not going to do that” (Participant #16) (Table 3).

Table 3. Representative quotations demonstrating surgeons’ communication priorities.

These priorities include: 1. Clarifying operative intent, 2. Disclosing uncertainty, and 3. Establishing prognostic alignment.

Themes	Representative Quotations
Clarifying Intent	I tell them it’s not curative, and I identify the focus that the intervention is for. If the focus is a bowel obstruction, then I make sure they understand that it’s a bowel obstruction that they’re getting an operation for…There’s a finite point of attack, a hard target, and there is a finite expectation.” (Participant #8)
	“But I think the patient needs to be educated in the process and be able to know what your thought processes are so they can follow along.” (Participant #5)
	“[P]articularly for people who aren’t surgeons, there is this sort of, ‘Is it curative or is it palliative?’…I think not just for the patients, I think for the whole care team, being able to sort of pull out that the intent is control and not cure would be helpful.” (Participant #17)
	“[O]ne of the first things you dictate in a surgical note is…’What’s the indication?’ This is being done for diagnostic purposes. This is being done for potentially therapeutic purposes. So if we’re putting that in our notes, shouldn’t we be having that conversation with the patients?” (Participant #5)
Disclosing Uncertainty	“Informed consent is a very charged term. It’s hard to, really, I don’t have enough information to know what’s always the right answer…But at least you’ve given them that opportunity to consider what really can be expected and what might be too much to expect.” (Participant #13)
	“[T]he likelihood of cure is extremely low…And I need you to understand that before we sign up to do this together.” (Participant #2)
	“I would also describe the ways in which we wouldn’t be able to necessarily predict the trajectory of the metastatic growth.” (Participant #1)
Establishing Alignment	“What is our goal? Our goal is to keep you from having to come back to the hospital, hopefully getting you to eat again…So do a colostomy, you know making sure they’re okay with what a colostomy means…and say, ‘Is that trade-off worth it to you[?]’…and just make sure that their goals and understanding is aligned with what we’re offering….I think if everyone’s on the same page, you know as long as we’re all aligned and everybody’s upfront and straightforward and knows what we’re all agreeing to do, then I think it comes down to really the patient is the boss.”” (Participant #5)
	“I think documenting the intent of the operation, particularly for cancer, is really important…[Y]ou need to know if the outcome of that operation really aligned with what the patient’s goals are.” (Participant #6)
	“The only thing that I find helps me when I’m thinking about these concepts is the knowledge of…why I’m doing it and how aggressive I should be surgically because that helps me align with my patients and their goals.” (Participant #7)

Theme 2: Disclosing Uncertainty

While participants valued clarifying the operative intent, they also acknowledged that, for patients with incurable cancer, their prognoses and the role of surgery is complicated by uncertainty (Table 2) – and that the uncertainty itself should also be expressed. For example, one participant stated, “I would also describe the ways in which we wouldn’t be able to necessarily predict the trajectory of metastatic growth” (Participant #1), highlighting the inclination to disclose their uncertainty. For many participants, this disclosure or admission served to temper patients’ expectations or prompt them to shift their goals: “I don’t have enough information to know what’s always the right answer…But at least you’ve given [the patient] the opportunity to consider what really can be expected and what might be too much to expect” (Participant #13). By disclosing the lack of evidence to support decision-making, the surgeon ensures that the patient also recognizes the uncertainty and restructures their expectations appropriately. (Table 3).

Theme 3: Establishing Alignment

Participants surmised that both their efforts to clarify treatment intent and to disclose their uncertainty would ultimately help establish alignment with patients, to ensure that “[the patient’s] goals and understanding is aligned with” the surgery being “offer[ed]” (Participant #5). The theme of alignment between surgeons and patients was heavily reinforced throughout interviews. This alignment often centered around ensuring patients goals were consistent with the surgeon’s perception of operative intent, or at least tempered by the inability to predict prognoses or operative efficacy (Table 3).

DISCUSSION

Our findings elucidate the paradigm through which cancer surgeons understand the goals of non-curative surgery and reveal the role that uncertainty plays in their communication practices. We found that cancer surgeons describe the overarching goal of non-curative surgery as preventing disease progression, and more specifically, as operations that help patients live longer and/or live better. When communicating about non-curative surgery, our participants valued transparent communication around surgical risks and operative intent. In the context of the high levels of uncertainty inherent to treating incurable cancer, participants also prioritized disclosing their uncertainty. The dual acts of clarifying treatment intent and disclosing uncertainty served to establish alignment with patients. This alignment signifies concordance between patients’ and surgeons’ goals in the context of mutual recognition that patients’ prognoses and the role of surgery in managing their cancer may be highly unpredictable.

Participants in our study overwhelmingly agreed on the importance of conveying treatment intent; yet, there is often a wide gap between clinician intent and patient expectation. Prior studies have demonstrated that patients with advanced cancer often misinterpret the purpose or overestimate the expected outcomes of cancer treatments,^4,5 including operative interventions.⁶ Additional work by Batten and colleagues showed that physicians caring for patients with cancer often use treatability statements (e.g., “This is a treatable condition”) and patients interpret these phrases as positive indicators, even when the clinician’s intent is not to suggest that treatment will improve prognosis or quality of life, but rather just to state the fact of an available treatment.^11,16 Phrases like “preventing disease progression,” which surgeons repeated in our interviews, may be perceived similarly to treatability statements, and require further clarification by physicians. Physician-patient collusion also likely exacerbates the gap between clinicians’ and patients’ understanding of treatment goals; in a four-year ethnographic study, The et al. observed patients with advanced lung cancer and described how physicians and patients colluded to sustain false optimism about the potential for recovery when, in fact, death was imminent.¹³ The et al. found that doctors contributed to this collusion by withholding prognostic information, focusing on treatment options, and using ambiguous language – much like treatability statements. While our findings support that surgeons highly value clear and forthright communication around treatment intent, the literature reveals that surgeons and other clinicians face significant communication barriers when discussing treatment intent for patients with advanced or incurable cancer.

Despite these communication barriers, establishing explicit treatment goals is a requirement for clinician documentation. The 2024 American Society of Clinical Oncology-Oncology Nursing Society standards for antineoplastic therapy administration states that clinicians must document the goal of treatment as either palliative or curative.¹⁷ Similarly, the 2020 American College of Surgeons Commission on Cancer (CoC) accreditation standards require surgeons to document in synoptic operative reports whether or not a case was performed with curative intent.¹⁸ These policies, while well-intended, could force clinicians to mischaracterize operative intents or confine them to a false binary. As we’ve described, the language used to describe the spectrum of non-curative care is limited to “palliation” and therefore, fails to capture the goals of non-curative therapies for asymptomatic patients. We are not the first to recognize a linguistic shortcoming: Fekete and colleagues recently proposed a three-tiered nomenclature including curative, palliative, and “potentially life-prolonging” therapies in medical oncology.¹² However, Fekete et al. did not solicit feedback on this term. When we proposed the term “disease-control surgery,” participants’ opinions were divided as to whether the term was overly optimistic or too pessimistic, suggesting that our phrase – much like “treatable” – may be too ambiguous in practice. In their recent work on the “better conversations” framework, Schwarze and colleagues have advocated for surgeons to describe at least one of four operative goals: helping patients live longer, feel better, prevent disability, or establish a diagnosis.¹⁹ Our work substantiates their efforts by demonstrating that, when offering surgery to patients with incurable malignancy, surgeons rely on the goals of living longer and better, but further work is needed to explore the clarity with which these goals are communicated and how patients interpret these goals when making care decisions.

Our findings led to the development of a conceptual model (Figure 2) reflective of surgeons’ perspectives on communication about non-curative surgery, which ultimately results in establishing alignment with patients. We have previously reported on the idea of “prognostic alignment,” which we defined as the effort of the multidisciplinary teams caring for seriously ill patients to develop a unified prognostic narrative, and then to share that narrative with patients or their proxies.²⁰ We did not expect “alignment” to emerge as a theme in this study. However, our participants described not only prognostic alignment, but a broader alignment: the mutual recognition of the uncertainty involved in non-curative surgery and subsequent expectation-setting within the context of such uncertainty. Based on these findings, we hypothesize that establishing alignment – through clarifying treatment intent and disclosing uncertainty – may reduce the use of ambiguous language and, perhaps, offers an antidote to lessen the degree of physician-patient collusion. Further work is needed to identify the optimal communication maps for non-curative surgical care and to understand patient perspectives on communication strategies.

Figure 2. Framework for cancer surgeons’ communication priorities.

Clarifying treatment intent and disclosing uncertainty enables patients to shift or reconfigure their expectations in order to achieve alignment with their providers.

Limitations

The nature of our study limits our findings’ generalizability as this is exploratory, hypothesis-generating research. Although clarity around operative intent, the disclosure of uncertainty, and alignment were communication priorities for the surgeons we interviewed, our participant pool skewed toward surgical oncologists practicing at academic centers. Furthermore, the specificity of our case scenarios – focused only on melanoma – restricts the interpretation of these findings, as many participants clinically focus on non-melanoma malignancies. Additionally, this study raised many questions we were unable to answer. For example, the idea of preventing disease progression was repeatedly raised, but we did not capture participants’ understanding of the concept as this was not recognized until the time of analysis. Lastly, as we only interviewed surgeons, our findings do not indicate how patients perceive these communicative efforts. Future efforts will focus on ascertaining through direct observations of surgical clinic visits how communication practices are carried out. Furthermore, we plan to gather patient perspectives through semi-structured interviews. We will compare and contrast expressions of operative intent relayed in clinic visits with both patients’ and surgeons’ interpretation of the operative intent. We hope that understanding specifically how intent is communicated and understood can lay the foundation to advocate for optimal language to for describing operative intent. Or should no such language exist—which may well be the case—we hope to develop assessment tools to enable surgeons and their patients to check for shared understanding of operative intent, expected outcomes, and intended goals of non-curative surgery.

Conclusions

This study delineated cancer surgeons’ paradigm for the goals of non-curative surgery and showed how surgeons emphasize the uncertainty inherent to non-curative cancer care. We found that this uncertainty drove surgeons to try to 1) clarify operative intent and 2) disclose the fact of their uncertainty around prognosis and potential outcomes. In doing so, patients can temper their expectations and align with their surgeons on what non-curative surgery can – or cannot – achieve.