We enjoyed the paper by Knotts et al. regarding the values of patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS±HIPEC).1 As the definition of value-based care is evolving, this paper was important in that not only did it address the physical and mental quality of life (QoL) of patients undergoing CRS±HIPEC but it also explored how patients prioritize different components of their care and care outcomes.

The study used social media-based cancer support groups to recruit participants, which allowed for broad, international responses. Both mental and physical QoL in patients undergoing CRS±HIPEC were lower than the average population (44 ± 13 and 41 ± 11, respectively, compared with 50 ± 10), but these metrics improved over time from the procedure. Additionally, the QOL metrics were statistically very similar in CRS±HIPEC patients as those with gastrointestinal/hepatobiliary cancers undergoing surgery who did not undergo CRS±HIPEC.

One of the unique results reported in the paper was the ranking of priorities of CRS±HIPEC patients. The majority (67%) of respondents ranked overall survival as their highest priority and along with functional independence, emotional well-being and treatment experience were all rated as extremely important, with scores of more than 3.5 on a 5-point scale. The exception to this was cost, which was rated low on the Likert scale, with only 5% of patients ranking this as most important.

One factor that was not captured in the demographics was country of origin and, specifically, private or universal healthcare. Many respondents may be from public health care systems where cost of treatment may not be covered by the respondent, or from private systems, with appropriate insurance or financial means such that cost is less relevant. The authors acknowledge that the results may be skewed by these and other similar factors.

Value-Based Health Care and Cytoreductive Surgery + Hyperthermic Intraperitoneal Chemotherapy (CRS+/− HIPEC)

Value-based health care was originally described by Porter and Teisberg (value = quality/cost), with the aim of improving outcomes at a lower overall cost of care.2 This developed in the context of rapidly rising healthcare expenditures, in particular in the US healthcare system.3 CRS±HIPEC has historically been considered a high-cost procedure, with the majority of the cost being driven by length and intensity of care, including inpatient hospital stay related to the index procedure and management of subsequent complications.4 As surgical oncologists providing this procedure, we can mitigate some cost by utilizing enhanced recovery after surgery (ERAS) principles and other patient pathways to minimize in-hospital days, with deliberate and focused patient education related to preoperative and postoperative care.5,6 Standardization of some perioperative approaches and experience in recognition and management of complications are not as well characterized for the CRS±HIPEC procedure, but would be relevant to cost.7 Some recent work on defining quality measures and standards for CRS±HIPEC programs are critical to discussion regarding value and should be instrumental to the development of new CRS±HIPEC programs that can provide high-quality surgical oncology care.8 This may have an impact on pay-for-performance bundles in value-based care and could set the standard for which additional quality improvement may be based.

CRS+/− HIPEC: Who, Where and How—The Benefit of Qualitative Methodologies

While seeking to understand the patient-driven factors of a decision to proceed and invest in the CRS±HIPEC procedure and the recovery afterwards, it is important to critically consider the demographics and social context. Surveys such as this can provide insight into the experience of many patients, including, admittedly, the most privileged and supported groups who have selected themselves into the process and provided voluntary survey response, in this case predominantly White (92%) females (87%). It would be interesting to evaluate responses from all patients referred for the procedure to determine whether priorities might differ between those who proceeded and those who did not.

The use of qualitative research methods is essential to understand the patient perspective as it is embedded in their social context. Although such qualitative studies are still voluntary for patients, selection of patients from diverse cultural and socioeconomic backgrounds would be possible. Qualitative methodologies offer many advantages, including the opportunity for more in-depth probing of experiences of members of the non-majority group.

The current report reinforces previous work that has established a return to baseline QoL sometime in the period 6–12 months after surgery, regardless of postoperative morbidity.10 Phases to recovery would support assessments over multiple time points that would be more informative of trajectory, and suggests the concept of value may be a dynamic concept from the patient perspective. Feelings of depression were common in a previous cohort of patients who underwent in-depth interviews after HIPEC,10 and this might be expected to influence a patient’s description of the emotional and mental cost of the experience. This may differ depending on when it was evaluated in the recovery or survivorship journey.

Negotiating ‘Value’

Although value has the connotation of monetary cost for the service received, value in surgical oncology procedures has been described as multifaceted and complex.9 This complexity may be related in part to how cost and impact are measured, such as direct financial costs or other patient-reported outcome or QoL measures. Some of these benefits or costs may be acute or long-term and may be difficult to quantify (ex: decreased time to re-accumulation of symptomatic ascites). It is critical to recognize that value and cost to cancer patients, in particular for complex surgical oncology procedures such as CRS±HIPEC cannot be assumed to be homogenous across similar patient populations. Even within the CRS±HIPEC patient population, great diversity exists with respect to prognosis, treatment options available, and potential for longer-term survival, and thus what ‘value’ a patient in their particular situation can derive. Surgical oncologists should advocate for values that resonate with patients and caregivers, given the unique patient experience within the CRS±HIPEC journey.

Conversely, CRS±HIPEC is not an appropriate therapy for all patients with peritoneal metastases from colorectal cancer, appendix cancers, and appendiceal neoplasms. Principles of patient selection for the procedure, based on patient, tumor, and treatment response factors, are well-established, and surgical oncologists, as stewards of resources, must navigate this path carefully, while managing patient and caregiver wants and expectations. In the heterogeneous patient population eligible for CRS±HIPEC, it is acknowledged that for many, this will not be a curative procedure; it can provide more durable palliation than other interventions; for example, a period of time free of the burdens and morbidity of systemic treatment, or of best supportive care. Understanding what patients deem a priority during that time period is essential to the ability to offer effective palliation. It is during those critical conversations between patient and surgical oncologist, when CRS±HIPEC is considered, where the definition of value to the patient, and the chance of realizing such value, must be clarified in sufficient detail for informed decision making.

Future Directions

A critical point to consider in the value-based care model is how research and development of programs and treatments occur, using a cost-sensitive approach. Understanding the advanced nature of disease in many patients undergoing CRS±HIPEC, clinical trials, new treatments (systemic or intraperitoneal), and others are of utmost importance and should not be minimized in relation to concern for cost or resources. For this purpose, it is similarly important that surgical oncologists and other clinicians routinely partner with patients and advocacy groups for logical and focused study design, taking into account patient values and priorities.