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ASCO guideline recommends early integration of palliative, standard oncology care

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November 9, 2016

Patients with advanced cancer should receive dedicated, early palliative care concurrently with standard oncology treatment, according to ASCO’s updated guidelines published in Journal of Clinical Oncology.

“The key update is that there is growing evidence and very strong consensus of the benefits of palliative care,” Betty R. Ferrell, PhD, FAAN, professor in the department of population sciences and director in the division of nursing research and education at City of Hope Medical Center, told HemOnc Today. “There is also strong evidence that implementing palliative care earlier in the course of disease improves patient quality of life and symptoms, as well as family caregiver quality of life and distress.”

Betty R. Ferrell

Ferrell and colleagues of an expert panel tasked with updating ASCO’s 2012 provisional clinical opinion on palliative care reviewed nine randomized clinical trials and meta-analyses and one quasiexperimental trial published from March 2010 to January 2016. The panel also conducted secondary analyses of the five randomized controlled trials used for the 2012 guideline.

A review of these trials showed early palliative care improves quality of life, reduces depression and improves satisfaction with care. Further, early palliative care reduced the use of chemotherapy near end of life for patients with lung cancer and increased enrollment in hospice. One trial also demonstrated a 2.7-month survival improvement with early palliative care.

Based on those findings, the panel gave a strong recommendation that patients with advanced cancer — defined as those with distant metastases, late-stage disease, cancer that is life limiting, or with a prognosis of 6 to 24 months — be referred to interdisciplinary palliative care teams that provide inpatient and outpatient care early in the course of their disease.

For newly diagnosed patients with advanced cancer, the expert panel suggested early palliative care involvement within 8 weeks of diagnosis.

Ferrell and colleagues described essential components of palliative care as:

  • rapport and relationship building with patients and caregivers;
  • symptom, distress and functional status management — such as for pain, dyspnea, fatigue, sleep disturbance, mood, nausea or constipation;
  • exploration of understanding and education about the disease and prognosis;
  • clarification of treatment goals;
  • support of coping needs;
  • assistance with medical decision-making;
  • coordination with other care providers; and
  • provision of referrals to other care providers.

In addition, the panel concluded that family and friend caregivers also may benefit from palliative care services. This may include telephone support for those who live in rural areas, in addition to education, referrals and face-to-face meetings with nurses, social workers and other providers.

“The key issue for patients and families is that there is still a tendency to believe that palliative care is the same as hospice and, thus, that it should be saved until the end of life,” Ferrell said. “We need greater patient and family understanding that palliative care applies throughout the trajectory and has great benefit to help patients get through treatment, and is also very helpful during survivorship.”

For patients with high symptom burden and/or unmet physical or psychosocial needs, the panel recommended outpatient cancer care programs use palliative care clinicians to complement existing program tools. Services such as nurse navigation, geriatric oncology and pain services can be used in early phases of care, and patients can be transitioned to palliative care and end-of-life programs in late phases.

For instance, a randomized controlled trial of 66 patients from the Netherlands with incurable upper gastrointestinal cancer reported greater satisfaction and lower burden among patients and caregivers assigned a nurse-led palliative care follow-up in the patient’s home compared with patients who had follow-up at a clinic. Costs per patient with nurse-led intervention also were 38% lower than with clinic visits.

Researchers noted that funding for palliative care research is limited and that a broader spectrum of patients with cancer needs to be evaluated.

“It is worth noting that most all evidence has come from solid tumor populations and there is a great need for integration of hematologic malignancies as well,” Ferrell said. – by Chuck Gormley

For more information:

Betty R. Ferrell, PhD, FAAN, can be reached at bferrell@coh.org.

Disclosure: Ferrell reports no relevant financial disclosures. Please see the full study for a list of all other panel members’ relevant financial disclosures.