"It's Either Have Surgery or Die": How Patients Perceive the Choice to Undergo High-Risk Abdominal Surgery for Cancer

To examine how patients undergoing high-risk abdominal cancer surgery perceive the decision to proceed with surgery, particularly regarding whether surgery is experienced as a choice or a perceived necessity.

Patients considering high-risk abdominal cancer surgery face decisions about whether or not to proceed with surgery, yet prior work suggests that patients may not fully perceive surgery as a choice. How patients make sense of surgical decisions remains poorly understood.

A qualitative study was conducted using semi-structured interviews with adults scheduled for or recently undergoing curative-intent abdominal cancer surgery at 2 academic centers from 2023 to 2024. Thirty-four participants completed 45- to 60-minute in-depth interviews exploring expectations, decision-making experiences, and perceptions of surgical choice. Transcripts were deidentified, coded by a multidisciplinary team, and analyzed using qualitative content analysis informed by grounded theory techniques, with iterative content mapping to identify cross-cutting themes.

Participants described a continuum of perceived choice. Some recalled surgeons explicitly offering options and felt they were making an intentional choice, although others viewed surgery as technically optional but effectively unavoidable given a perceived lack of meaningful alternatives, their desire for a cure, or strong recommendations from clinicians or family. A subset reported no perceived decision at all, describing surgery as a predetermined step or an event that simply happened. Across categories, patients frequently equated surgery with survival, which shaped whether alternatives felt viable. Surgeon communication and patient perception did not consistently align, as explicit options did not always translate into a perceived sense of agency.

Patients considering high-risk cancer surgery often perceive limited or no choice, even when surgeons describe options. Recognizing how patients interpret choice may help refine shared decision-making approaches and guide the development of communication tools for complex surgical decisions.