To the Editor: A recent MJA Supplement discusses prognostic and end-of-life communication for health professionals on the basis of a systematic literature review and an expert advisory panel.1 It is usually the case that malignant disease is diagnosed after biopsy, and this is usually undertaken by a surgeon. In a consecutive series of 100 patients presenting with a lesion in a bone with no past history of malignancy, the lesion was the presenting feature of systemic malignancy in 44 of those patients.2 Hence, it is usually the surgeon’s role to advise the patient (and caregivers) that the patient has a terminal disease and, in some cases, the prognosis can only be measured in weeks. It will be obvious that this can be a significant shock to all, particularly when there was no prior indication that malignancy was a possibility.

I note that not one of the 35 experts was a surgeon. I also note that surgery as palliation is given virtually no role other than a brief mention in Box 11, despite the well documented role of surgery.3 It has been my experience that the most common question asked by patients with the diagnosis of a terminal malignancy is about the role of surgery; the question “Why can’t you just cut it out?” is a universal feature. This has not been addressed.

It is my sincere hope that further expert advisory panels addressing this area become truly multidisciplinary and include perhaps the most relevant discipline — surgery.

In reply: We agree that the content area of these guidelines is very relevant for surgeons, as for all health professionals involved in the care of adult patients with advanced life-limiting illnesses and their caregivers. Surgical representation on our expert panel would have been very useful. We agree that surgery has an important role in terms of palliative treatment options that may be available for certain clinical circumstances.

The issue of how to respond to the question “Why can’t you just cut it out?” is an important one. We believe that the principles outlined in these guidelines would be relevant when responding to this question, but would welcome specific suggestions from Clayer and other surgeons about how they respond to such patients. We would hope to include these suggestions along with other input from surgeons in any future update of these guidelines.