Advocates call for early integration of palliative care into cancer therapy

  • HemOnc Today, November 10, 2013

Several randomized studies conducted in the past few years reveal the clinical benefits of palliative care for patients with cancer, particularly if it is utilized at or soon after diagnosis.

Based on study findings, the National Comprehensive Cancer Network released guidelines in 2011 that suggest palliative care be offered throughout the entire course of cancer treatment.

A year later, ASCO published a provisional clinical opinion that recommended palliative care be offered at diagnosis for patients with metastatic disease, as well as for all patients with high symptom burdens regardless of long-term prognosis.

Yet, patient and physician perceptions, a shortage of providers and the belief that symptom and stress relief yields little reward in the pursuit of value-based care have slowed the widespread adoption of this approach.

Consequently, many associations and physician advocates are intensifying their pleas that providers integrate palliative care into the treatment paradigm early rather than limiting it to a component of end-of-life care.

“If we are committed to the best cancer care in this country, then we will be committed to ensuring that palliative care is as much a part of comprehensive care as chemotherapy, radiotherapy or surgery,” said Charles F. von Gunten, MD, PhD, vice president of medical affairs for hospice and palliative care for OhioHealth, a network of hospitals and health care organizations based in Columbus.

HemOnc Today spoke with several clinicians about the benefits of palliative care, the advantages associated with its early integration in the treatment process, and the barriers that must be overcome to make this become standard practice.

A key partnership

About 1.6 million people in the United States will be diagnosed with cancer in 2013, according to data from the SEER database.

Proponents suggest many of those patients would benefit from palliative medicine, designed to help manage symptoms, pain and complications associated with serious illness and maximize patients’ quality of life.

The partnership of oncology specialists with palliative care principles and practices assures patients are in the best possible condition to handle treatment and its side effects, according to Diane E. Meier, MD, FACP, director of the Center to Advance Palliative Care at Icahn School of Medicine at Mount Sinai. 

The partnership of oncology specialists with palliative care principles and practices assures patients are in the best possible condition to handle treatment and its side effects, according to Diane E. Meier, MD, FACP, director of the Center to Advance Palliative Care at Icahn School of Medicine at Mount Sinai.

Source: Photo courtesy of Center to Advance Palliative Care

“The partnership of oncology specialists with palliative care principles and practices assures that patients are in the best possible condition to handle the treatment and its side effects and are able to be strong enough to complete an appropriate course of therapy,” Diane E. Meier, MD, FACP, director of the Center to Advance Palliative Care at Icahn School of Medicine at Mount Sinai, said in an interview. “The data are very clear that patients who are in pain or who are depressed are far less likely to complete their regimens and have a higher risk of mortality. The data are also increasingly clear that patients who get palliative care at the same time as their cancer management from their oncologist not only feel better — as do their families — they also live longer.”

In a study published in 2010 in The New England Journal of Medicine, Temel and colleagues determined early integration of palliative care in patients with metastatic non–small cell lung cancer improved outcomes.

The analysis included 151 newly diagnosed patients who were randomly assigned to standard cancer treatment with or without early palliative care. Researchers assessed quality of life and mood at baseline and at 12 weeks. By the 12-week mark, 27 patients had died, and 107 patients were able to complete the assessments.

Analysis with the Functional Assessment of Cancer Therapy- Lung (FACT-L) scale (score range, 0-136) showed patients in the early integration group had higher mean quality-of-life scores (98 vs. 91.5; P=.003) and reduced incidence of depressive symptoms (16% vs. 38%; P=.01). Fewer patients assigned to early palliative care underwent aggressive end-of-life care (33% vs. 54%; P=.05), yet they still demonstrated longer median survival (11.6 months vs. 8.9 months; P=.02).

Project ENABLE II — a randomized controlled trial conducted by Bakitas and colleagues — showed similar results. The analysis included 322 patients with advanced cancer treated at an NCI-designated comprehensive cancer center and affiliated clinics. The most common diagnoses were cancer of the gastrointestinal tract (41%), lung (36%), genitourinary tract (12%) and breast (10%).