When is surgery futile? A systematic review of conflicting definitions and patterns in surgical care for advanced gastrointestinal cancer

Objective

To report current definitions of futility and futility rates for patients undergoing advanced gastrointestinal (GI) cancer surgery.

Background

Surgery remains the primary treatment option for selected patients with advanced GI cancer, demonstrating significant survival benefits when successful. However, surgeries that fall short of expectations may be viewed as ‘futile’. Despite the clinical and ethical importance of futility, no universally accepted definition of futility exists in this cohort.

Methods

MEDLINE, CINAHL, Scopus, Embase, Cochrane Register, and Web of Science were searched on 26 September, 2024, adhering to PRISMA guidelines. Studies involving curative intent surgery for advanced GI cancers were included. Two independent authors extracted study characteristics, futility definitions and rates. Risk of bias was assessed using the JBI Critical Appraisal Checklist.

Results

23 studies were included (74 839 patients). Liver cancer (n = 10) and colorectal cancer (n = 7) were the most studied cohorts. Definitions of futility varied widely, and were broadly categorised into recurrence (n = 12, 52 %), mortality (n = 5, 21 %), or both (n = 5, 21 %), with heterogeneous timeframes. Irrespective of definition, the average futility rate was 27.3 %, with pancreatic cancer reporting the highest rate (31.9 %). One study defined futility qualitatively (harm outweighing benefit). Notably, no studies incorporated patient perspectives on futility.

Conclusion

Significant heterogeneity exists in futility definitions for advanced GI malignancy surgery, limiting generalizability. The lack of patient perspectives represents a critical gap. Future research should prioritize developing a consensus definition that includes diverse stakeholder viewpoints to improve clinical decision-making and patient-centred care.