Supplement:

Supplemental Table: Surgeon practice characteristics and discussion of cure

Supplement 1: Survey

Supplement 2: Respondent free-text answers to survey questions.

Figure s1: Respondent self-reported definitions of cancer “cure.”

Supplement 1: Supplemental Table: Surgeon practice characteristics and discussion and

perception of cure

CharacteristicUse word

“cure”

Do not use word

“cure” p

Rank cure first or second¥

Rank cure >2 p

Gender 0.22 0.06 Male 65 (39.6) 99 (60.4) 94 (60.3) 62 (39.7) Female 12 (29.3) 29 (70.7) 18 (43.9) 23 (56.1)Practice Type 0.30 0.56 Academic practice or university hospital 62 (39.5) 95 (60.5) 87 (58.3) 63 (42.0)

Private practice or community hospital 15 (31.3) 33 (68.7) 25 (53.2) 22 (46.8)

Percent clinical 0.28 0.11 ≥50% clinical 66 (36.3) 116 (63.7) 96 (54.9) 79 (45.1) <50% clinical 11 (47.8) 12 (52.2) 16 (72.7) 6 (27.3)Years in practice <0.01 0.19 ≥20 44 (46.8) 50 (53.2) 58 (62.4) 35 (37.6) <20 30 (28.0) 77 (72.0) 53 (53.0) 47 (47.0)Number of operations for cancer per month 0.02 0.24

>15 29 (29.3) 70 (70.7) 61 (61.6) 38 (38.4) ≤15 46 (45.5) 55 (54.5) 50 (53.2) 44 (46.8)Number of complex operations for cancer per month†

0.63 0.24

>5 35 (36.1) 62 (63.9) 48 (52.8) 43 (47.2) ≤5 41 (39.4) 63 (60.6) 63 (61.2) 40 (38.8)Fellowship training§

Total 77 (37.6) 128 (62.4) 112 (54.9) 85 (43.1) Surgical Oncology 43 (35.8) 77 (64.2) 0.54* 65 (56.5) 50 (43.5) 0.91*

Hepatopancreatobiliary 15 (37.5) 25 (62.5) 0.99* 19 (48.7) 20 (51.3) 0.25*

Transplant 13 (50.0) 13 (50.0) 0.16* 16 (64.0) 9 (36.0) 0.44*

Breast 4 (22.2) 14 (77.8) 0.16* 10 (55.6) 8 (44.4) 0.91*

¥Among 197 completing rankings

† Complex operations were those defined by >1% risk of mortality or >10% risk of morbidity

§Chi-square tests performed on all subspecialty represented by more than 5% of the respondents

*vs all other respondents (i.e., non-surgical oncology trained, non-HPB trained, etc…)

Supplement 2: Survey

Supplement 2: Respondent free-text answers to survey questions.

What other way do you use to define cure? Respondent free-text answersThe patient dies at the same time they would have died [otherwise] and not from cancer.It depends of type of cancer.Intention that patient will live longer without recurrence.If a patient asks about the probability of cure I generally ask them what that term means to them, giving several of the [proposed] options as possibilities.I use the term “potentially curable.”It depends on the patient.

In what other way do you discuss cure? Respondent free-text answers“This particular cancer cannot, therefore will not recur.”It depends on the patient's understanding of what cure means to them.I use both relative and absolute language.I try to stay away from numerology and use analogies to help people understand and comparisons like “an hour of being a 60 year old man”, but some patients want numbers so I give them numbers.I never provide chances of cure because I don't discuss cure. The most I [say] is that at a certain point in time after the surgery you will not have any known cancer. I do at times discuss 5 year disease-free survival, but I don't declare that is a cure. It depends on the patient’s ability to understand.I use a combination appropriate for the patient.I say “chances are excellent.”

What other barriers are there to discussing cure? Respondent free-text answersNot every patient wants to know about cure, as other goals might be more relevant.The education of a patient and his or her capability to understand complex information.Sometimes patients get distracted by terminology of “cure” by other doctors, family, or friends. Some patients specifically indicate when asked…that they do not want to discuss [cure].Poor patient understanding about the overall objectives of treatment, cure being just one part. The patient’s or family’s fixation that I 'got it all'.Patients don't remember discussions, or [they] remember statistics incorrectly.Patients are simply overwhelmed with the diagnosis of cancer and the decision to go to the [operating room]. Most do not seem interested in discussing cure, even when I bring it up.Patients may not be realistic or [may] hear what you say versus what they want to hear.The patient never asks.Patients attach a lot of significance to anything [a doctor] says. If attempt to quantify cure prior to final pathology the patient may feel misled when things change on final path.

I like to [discuss] treatment options, and [their] pluses and minuses [first], and those are often long and in-depth discussions, with each point leading to more algorithms. When surgery is done and the final path is in (especially if oncotype or other information is then available) then we have a better picture to discuss cancer risk in relation to other health factors…what that means, quality of life, living life, adjuvant treatment options, cure as it relates to risk of local or metastatic recurrence, the difference between the two and how we still have hope even in these circumstances. This is a large discussion that I think fits in better [after an operation]. I often find [that] patients need to revisit that discussion at different time points …as they get further away from diagnosis and treatment…things sink in better and they want to discuss and hear it again, especially as long-term treatment side effects start to become apparent. I'm not a fan of the word cure but each patient seems to have a way they like to discuss it, some very statistical, some very hopeful, along the way I usually figure it out and adjust the conversation to them. I am usually brutally honest with all my cancer patients.For the cancers I treat, late recurrences can happen, [though] not frequently, and the cancers can be unpredictable. Therefore I usually don't discuss cure but focus on risk of recurrence based on data in the literature.Each patient should be treated as an individual and the provider should gauge the individuals' interest in discussing the topic of cure.

Difficulty defining treatment risks and tumor recurrence risks in meaningful way in selected patients.I think surgeons should definitely should wait for pathological diagnosis of ‘cancer' before recommending surgery and/or talking about cure.I mention that there is always a chance of developing recurrence or metastasis many years out from treatmentA limitation is that some patients don't want to know their chances of dying from the cancer, which is the flip side of cure. I try to assess their needs/wants in terms of information.“cure” may be defined differently between physicians and patients, and there may not be a “cure”.

Perceived Patient Goals of Cancer Care Respondent free-text answersUnderstand the treatment, potential side effects and outcomes to help with decision making in selecting treatments.Trying to be sure they are doing the right thing at the right time[They are] so unique to each patient.Not be a burden (financial or otherwise) on familyDifferent patients have different goals. Physicians need to help patients identify goals that are important to them (patients) and tailor treatment plans accordinglyBe pain free

Be able to answer people's questions about their care and learn enough about their disease process to be able to do their own research about it on the internet. It is very important for them to be able to compare their disease and experiences with others who have had the same disease. 'Survival' and discussion of the differences between overall and disease specific survival.

Figure s1: Respondent self-reported definitions of cancer “cure.”