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Tracheobronchial Stenting in the Terminal Care of Cancer Patients With Central Airways Obstruction^*

^* From the Department of Pulmonary Medicine, University Hospital Vrije Universiteit, Amsterdam, the Nertherlands.

Correspondence to: Tom G. Sutedja, MD, PhD, FCCP, University Hospital Vrije Universiteit, Department of Pulmonary Medicine, PO Box 7057, 1007 MB Amsterdam, the Netherlands; e-mail: TG.Sutedja{at}azvu.nl

	Abstract

TOP Abstract Introduction Materials and Methods Results Discussion References

 
Study objectives: To evaluate the palliative benefit of stent insertion in a group of patients with central airways obstruction due to terminal cancer.

Design: Retrospective analysis of the symptomatic score of patients immediately after stent insertion, and questionnaires completed by the general practitioner (GP) after the patients died at home.

Setting: Academic hospital, tertiary referral center for interventional bronchoscopy.

Patients and methods: Fourteen patients with imminent suffocation due to major obstruction of the central airways, caused by end-stage esophageal cancer (n = 5) and non-small cell lung cancer (n = 9), were referred for stent insertion. All prostheses were placed within 24 h after hospital admittance. Patients were then asked whether their symptoms had improved. After the patients died, a questionnaire was sent to each patient’s GP.

Results: All patients expressed immediate benefit after stenting. The average length of survival after stent insertion was 11 weeks (range, 0.5 to 34 weeks). Two patients died within 1 week in our hospital after stent placement. In the remaining 12 patients, the GP considered stent insertion in 7 patients to be worthwhile, no judgment was made in 4 patients, and stent insertion in 1 patient was regarded as futile.

Conclusion: Despite terminal disease and the fact that, in our country, patients may legally refuse any treatment and formally ask for euthanasia, the palliative benefit of stent placement should always be considered. All patients had immediate symptomatic relief afterwards. Retrospectively, the GPs responsible for terminal care at home still considered stent insertion worthwhile in 58% (7 of 12 patients) of cases. Stent placement should always be considered as part of the treatment of terminal cancer patients with imminent suffocation.

Key Words: palliative treatment • tracheobronchial cancer • tracheobronchial stents

	Introduction

TOP Abstract Introduction Materials and Methods Results Discussion References

 
Patients with imminent suffocation due to a central airways obstruction can be offered treatment with various endoscopic techniques. An intraluminal tumor can be treated with mechanical core-out, laser ablation, electrocautery, and, in case of extraluminal compression, by dilatation and stent insertion. Cryotherapy, photodynamic therapy, and brachytherapy are less practical, as immediate results are more difficult to obtain.¹

The indication for stent insertion is significant extraluminal compression causing severe symptoms such as stridor and dyspnea in patients with tracheobronchial malacia. Stent insertion can be performed using flexible and rigid devices. Advances in techniques to insert airway prostheses have provided clinicians with a variety of pneumatic dilators, and expandable metallic and silicone stents.

Studies describing patients undergoing stent placement for central airways obstruction have reported successful and immediate palliation in most of the patients.^{2 3} This seems to be true also for patients with end-stage disease.² However, many institutional centers involved in interventional bronchoscopy are usually tertiary referral centers; therefore, follow-up data may be incomplete. Only one prospective study³ showed that stent placement for patients with inoperable tracheobronchial cancer resulted in a significant decrease of dyspnea in the majority of patients who survived 3 months. Furthermore, although some studies^{2 3} reported late complications after stent placement, not much is known about the circumstances of death in these patients. Temporary relief of dyspnea may also lead to prolonged suffering and, thus, may not necessarily provide meaningful "palliation" from the patient’s point of view. Especially for patients with end-stage cancer, the definition of palliation and quality of life may be influenced by sociocultural factors. In the Netherlands, the doctor is formally obliged to inform the patient about the severity of the illness and the intent of treatment (curative or palliative). Every patient has the legal right to refuse any treatment. In terminal cancer, patients may formally apply for euthanasia and physician-assisted suicide; by acting according to the formal guidelines of the law, the doctor (usually the general practitioner[GP]) has the formal authority to grant this request to end terminal suffering. If properly executed, a "euthanasia" case may then be considered "legal" by the district attorney and the doctor involved will not be prosecuted according to law.

The aim of this study was to evaluate the palliative benefit of stent insertion in a group of patients with imminent suffocation due to central airways obstruction because of terminal cancer. As patients are fully aware of their terminal disease, one cannot be sure whether a successful stent insertion may ultimately result, albeit judged in retrospect, as another technical achievement performed by the specialist, which only results in prolonged suffering from the point of view of the patients and the GPs. This is because the interventional bronchoscopist is not the only one to judge the ultimate palliative benefit of stent insertion, and also because of the limited time spent in the total care of these patients. In terminal cancer care in the Netherlands, the GP is the key figure in the care of patients with terminal illness at home.

	Materials and Methods

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Patients were selected from a group of patients referred with severe symptomatic central airways obstruction from 1997 to 1999. Inclusion criteria were as follows: (1) end-stage disease lacking any curative option; (2) central airways obstruction due to extraluminal disease for > 50% of the tracheobronchial lumen; (3) stent insertion as the only alternative; and (4) imminent suffocation, with severe dyspnea and stridor at rest. Fourteen patients were included. Patient characteristics and underlying conditions are listed in Table 1 .

The symptoms score was graded immediately after stent insertion. If the patient was discharged and later died at home, a questionnaire was sent to the GP. Questions about the following were asked: (1) exercise tolerance or symptoms after stent insertion; (2) exercise tolerance in the last 2 weeks before death; (3) complications, if any, related to stenting; and (4) judgment of the ultimate palliative benefit of stenting in retrospect.

	Results

TOP Abstract Introduction Materials and Methods Results Discussion References

 
All 14 patients had severe dyspnea and stridor at rest prior to hospital admittance. In all patients, stent placement was performed within 24 h after arrival. Although all patients expressed immediate symptomatic relief of their dyspnea, exercise tolerance improved only in eight patients. A decline of the general condition prevented any meaningful exercise tolerance improvement in the remaining patients afterwards.

The average (± SD) length of survival after stenting was 11 ± 11 weeks (range, 0.5 to 34 weeks). Two patients died in the first week after stent placement in our hospital. The first patient (patient 5) died after stent migration 2 days after intervention, and after further intervention for stent repositioning was refused by the patient. This patient died with maximal palliative care (sedation) given. The second patient (patient 8) died 5 days after intervention, as a formal request for euthanasia was granted despite the fact that the stent was correctly positioned. The patient experienced esophageal stenosis and refused another stenting procedure for the esophagus as well as further treatment. The remaining 12 patients were discharged from our hospital. All of the GPs returned their completed questionnaires. Eleven patients died at home, and 1 patient died in a reference hospital. Ten patients died due to progression of the tumor without respiratory symptoms or recurrent obstruction. Two patients died due to respiratory distress. Evaluation in one patient showed tumor progression caudal and cranial of the stent; he refused further treatment and died soon afterwards in the hospital. The other patient died at home due to massive hemorrhage. No immediate complications of stent insertion were documented in the remaining patients.

Finally, seven GPs evaluated stent insertion to be meaningful palliation in retrospect (Table 2 ). Four GPs made no judgment. The anxious and depressed status of three patients after stent placement until death and the short survival time (2 weeks) in another patient were the reasons their GPs made the judgment of "no palliative benefit" of stent placement, despite the successful attempts and decrease of dyspnea immediately after stenting. One GP considered stent insertion retrospectively to be futile without giving any detailed reason.

	Discussion

TOP Abstract Introduction Materials and Methods Results Discussion References

All prostheses were placed using a rigid bronchoscope to safeguard optimal ventilation during the procedure. Currently available tracheal prostheses have been shown to significantly improve quality of life.^{7 8 9 10 11} However, there are a lack of studies comparing the palliative benefits of different types in large randomized trials.¹² Therefore, our choice of three different stent types was arbitrary. What was available at the time of insertion to achieve the simple objective of immediate reopening of the stenosis was considered good enough, as long as the stent could be properly placed.

The objective of this study was to evaluate the limit of palliation in borderline clinical situations in the event of terminal care. Palliative care is defined by the World Health Organization as the overall palliative care in the terminal phase of life, including emotional and psychological aspects. Therefore, palliative care contained much more than the scores of symptomatic benefit alone. Therefore, we included the GP to retrospectively judge the ultimate benefit. The GP plays a central role in the care of the terminally ill patient and knows the patient and his/her family well, but is not involved in the "technical approach" of central airways obstruction. For this reason, we believe that the GP is the most appropriate person to discriminate between living with acceptable quality of life vs prolong suffering by terminal cancer thanks to the successful stenting by the intervention bronchoscopist for the terminally ill at home.

The result of these questionnaires showed that despite the relatively short survival time, in only one patient did the GP retrospectively consider stent insertion to be futile. The majority of the patients (80%) died at home. Considering that all 14 patients were in direct danger of suffocation, only 1 patient ultimately died of recurrent tumor obstruction outside the stented area. From these results, it may be tempting to hypothesize that stent insertion may also be beneficial for many more patients who are not yet in the terminal stage of their illness.

We therefore conclude that even for patients with a very poor prognosis at their terminal cancer stage, stent insertion for central airways obstruction is not only a technical stunt, but must be considered for providing immediate symptomatic relief of dyspnea and worthwhile palliation. Despite the legal right of patients to ask for nonintervention, physician-assisted suicide, or euthanasia, one should not forget the potential of stenting to improve quality of life as part of care for patients with terminal cancer. This potential may be easily forgotten, especially when caring for patients for whom there is a legal possibility of openly discussing "life-ending issues," in the presence of prejudices that interventional bronchoscopy is a futile and dangerous business and may cause morbidity, provide little benefit, and increase suffering in individuals with major obstruction of their central airways due to terminal cancer.

	Footnotes

 
Abbreviation: GP = general practitioner

Received for publication September 25, 2000. Accepted for publication July 9, 2001.

	References

TOP Abstract Introduction Materials and Methods Results Discussion References

 

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