New Palliative Care Cancer Guidelines
October 10, 2012
According
to a recently issued provisional clinical opinion, palliative care
should be considered earlier in the course of illness for any patient
with metastatic cancer or high symptom burden.
Nearly half of all patients with
metastatic cancer have incurable disease, but these individuals can live
for years after their initial diagnosis. Palliative care can be used
during this period to improve quality of life (QOL) for patients and
caregivers. Palliative care emphasizes medically appropriate goal
setting, honest communication, and meticulous symptom assessment and
control.
Despite the documented benefits of using
palliative care in standard oncologic care, studies indicate that many
patients are not referred to these services until near the end of life.
Delaying palliative care reduces opportunities for clinicians to address
physical symptoms and the emotional, social, and spiritual needs
(see
also, The Burden of Pain & Depression in Cancer Patients).
Potential Benefits of Early Palliative Care Integration
In the March 10, 2012 Journal of Clinical Oncology,
the American Society of Clinical Oncology (ASCO) issued a provisional
clinical opinion (PCO) on integrating palliative care into standard
oncology care. The document was prompted by a growing body of research
demonstrating the benefits of this integration early in the care of
patients with metastatic cancer. Seven randomized controlled trials have
shown that providing early palliative care together with standard
oncologic care in patients with advanced cancer can be beneficial. These
benefits include:
Improved symptoms, QOL, and satisfaction.
Reduced caregiver burden.
More appropriate referral to and use of hospice.
Decreased use of futile intensive care.
Furthermore, most of these studies
demonstrated improved outcomes at a cost lower than that of standard
oncologic care alone. No trials to date have demonstrated harm to
patients and caregivers or excessive costs from early involvement of
palliative care.
Hurdles Ahead for Readily Available Palliative Care
Inpatient consultative palliative care
services are becoming more prevalent, but clinic-based and
community-based non-hospice palliative care services are only now
becoming more readily available (see also, Top 10 States Having Hospitals With Palliative Care).
Palliative care physicians and multidisciplinary providers will be
required to meet the anticipated growing demand. In the near future,
greater emphasis is needed to align health policy and reimbursement so
that palliative care use can be optimized.
Optimizing Palliative & Standard Oncology Care
Strategies to optimize concurrent palliative
and standard oncology care should be an area of intense research. In
the PCO, ASCO provided recommendations on areas where future research is
needed to address important gaps in knowledge. Studies are needed to
evaluate the optimal timing and venue for provision of palliative care.
More research into evidence-based reimbursement models that support
palliative care provision is also warranted. It would also be beneficial
to determine which components of palliative care have the greatest
impact across the continuum of care. This PCO is only a beginning step
in ASCO’s ongoing efforts to ensure that patients with advanced cancer
have access to high-quality palliative care. These efforts are critical
to addressing the complex needs of patients and their caregivers.
Additional Resources:
Smith TJ, Temin S, Alesi ER, et al.
American Society of Clinical Oncology provisional clinical opinion: the
integration of palliative care into standard oncology care. J Clin Oncol. 2012;30:880-887. Available at: http://jco.ascopubs.org/content/early/2012/02/06/JCO.2011.38.5161.full.pdf+html.
Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363:733-742.
Von Roenn JH, Temel J. The integration of palliative care and oncology: the evidence. Oncology (Williston Park). 2011;25:1258-1260, 1262, 1264-1265.
Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: Results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55:993-1000.
Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: A randomized control trial. J Palliat Med. 2008;11:180-190.
Meyers FJ, Carducci M, Loscalzo MJ, et al.
Effects of a problem-solving intervention (COPE) on quality of life for
patients with advanced cancer on clinical trials and their caregivers:
simultaneous care educational intervention (SCEI)—linking palliation and
clinical trials. J Palliat Med. 2011;14:465-473.
Bakitas M, Lyons KD, Hegel MT, et al.
Effects of a palliative care intervention on clinical outcomes in
patients with advanced cancer: The Project ENABLE II randomized
controlled trial. JAMA. 2009;302:741-749.
Meyers FJ, Linder J, Beckett L, et al. Simultaneous care: A model approach to the perceived conflict between investigational therapy and palliative care. J Pain Symptom Manage. 2004;28:548-556.
Pantilat SZ, O’Riordan DL, Dibble SL, et al. Hospital-based palliative medicine consultation: a randomized controlled trial. Arch Intern Med. 2010;170:2038-2040.
Rabow MW, Dibble SL, Pantilat SZ, et al. The comprehensive care team: a controlled trial of outpatient palliative medicine consultation. Arch Intern Med. 2004;164:83-91.
Temel JS, Greer JA, Admane S, et al.
Longitudinal perceptions of prognosis and goals of therapy in patients
with metastatic non-small-cell lung cancer: results of a randomized
study of early palliative care. J Clin Oncol. 2011;29:2319-23
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