Commentary

Palliative care in oncology: Dedication always, specialists often

Many of us in the oncology and palliative care communities read with great interest the guidelines from the ASCO Ad Hoc Palliative Care Expert Panel on the integration of palliative care within routine oncology care.

Building upon the 2012 provisional clinical opinion, these more formal recommendations highlight the regular delivery of dedicated palliative care services for all patients with advanced cancer, across inpatient and outpatient settings, and concurrent with cancer-directed treatments.

Further, the panel recommends referral to interdisciplinary specialty palliative care services as optimal, in complement with existing services provided by the oncology team. This is the most specific and direct recommendation of palliative care integration within routine oncology care, by the most influential and largest oncology membership organization in the world.

Arif H. Kamal, MD, MBA, MHS
Arif H. Kamal

This is a remarkable step forward in two regards.

First, the guidelines highlight the important role specialty palliative care services play in the care of all patients with advanced cancer. Optimally, this involves the integration of specialty services to complement the dedication by the primary oncology team in supporting patients’ and caregivers’ quality of life.

The authors remind us that the evidence base for outcomes that matter to patients (eg, quality of life, symptom improvement and potentially increased survival) alongside those that matter to clinicians and health systems (eg, acute care utilization and hospital readmissions) align around specialty palliative care. There no longer is any reasonable assertion of equipoise regarding the benefit of specialty palliative care services in routine oncology care.

Second, the guidelines remind us that dedication — “the act of devoting wholly and earnestly” — to the physical, emotional, cultural, social, psychological, spiritual, existential, legal, financial, informational and planning needs of serious cancers is our collective responsibility.

Further, the rededication of efforts to focus on quality-of-life issues is even more important in an era of unprecedented change. Health care reforms, along with significant anticipated changes with a new presidential administration, herald a future of shifting rules and regulations governing quality and payment.

Additionally, the extraordinary expansion of the cancer treatment armamentarium adds further complexity to cancer care delivery.

For example, the FDA approved 17 new treatment or supportive care drugs for cancer in 2015. These innovations will require oncologists to learn: 17 treatment regimens, including dose, frequency, administration route and treatment sequence; up to 30 indications for use; knowledge of at least 35 new major clinical trials; and mastery of 85 important side effects.

Attention to the typical concerns of new medications — such as formulary coverage, preauthorization, and evolving methods to address new or novel side effects — adds even more responsibility to the oncology team’s plate. Dedication to palliative care needs of patients with advanced cancer is critical, and yet oncology teams face challenges from multiple angles to deliver this care alone.

Along with the increasing calls for palliative care integration in routine oncology care, there is a need to address the existing challenges in palliative care delivery. These include the gaps in availability of specialty palliative care services to oncology teams, especially in the community. Although more than 90% of National Comprehensive Cancer Network members indicate an outpatient palliative care program, data outside large academic programs show an accessibility rate of less than 25%.

Further, the panel recommends integration of interdisciplinary palliative care services, defined by the TJC — formerly The Joint Commission — to include a physician, nurse, social worker and chaplain.

Data from the National Palliative Care Registry demonstrate that less than 25% of palliative care programs are resourced to incorporate all four professionals on their team. The specialty of palliative care has come a long way in its growth and acceptance, but key issues remain to be solved.

The new guidelines remind us that palliative care is a foundational component of comprehensive cancer care delivery. Our dedication to quality of life must be unwavering, incorporation of specialty palliative care clinicians must occur often, and continuing challenges in meeting these goals must be addressed. Our patients deserve no less.

References:

Calton BA, et al. J Natl Compr Canc Netw. 2016;14:859-866.

Clough JD, et al. J Oncol Pract. 2015;doi:10.1016/j.jpainsymman.2015.10.016.

Hui D, et al. J Natl Compr Canc Netw. 2016;14:859-866.

Kamal AH, et al. Ann Intern Med. 2015;doi:10.1001/jama.2016.6491.

Kamal AH, et al. JAMA. 2016;doi:10.1001/jama.2016.6491.

Smith TJ, et al. J Clin Oncol. 2012;doi:10.1200/JCO.2011.38.5161.

Spetz J, et al. Health Aff (Millwood). 2016;doi:10.1377/hlthaff.2016.0113.

For more information:

Arif H. Kamal, MD, MBA, MHS, is assistant professor of medicine in the department of medicine at Duke University School of Medicine, as well as member of Duke Cancer Institute. He can be reached at arif.kamal@duke.edu.

Disclosure: Kamal reports no relevant financial disclosures.

Many of us in the oncology and palliative care communities read with great interest the guidelines from the ASCO Ad Hoc Palliative Care Expert Panel on the integration of palliative care within routine oncology care.

Building upon the 2012 provisional clinical opinion, these more formal recommendations highlight the regular delivery of dedicated palliative care services for all patients with advanced cancer, across inpatient and outpatient settings, and concurrent with cancer-directed treatments.

Further, the panel recommends referral to interdisciplinary specialty palliative care services as optimal, in complement with existing services provided by the oncology team. This is the most specific and direct recommendation of palliative care integration within routine oncology care, by the most influential and largest oncology membership organization in the world.

Arif H. Kamal, MD, MBA, MHS
Arif H. Kamal

This is a remarkable step forward in two regards.

First, the guidelines highlight the important role specialty palliative care services play in the care of all patients with advanced cancer. Optimally, this involves the integration of specialty services to complement the dedication by the primary oncology team in supporting patients’ and caregivers’ quality of life.

The authors remind us that the evidence base for outcomes that matter to patients (eg, quality of life, symptom improvement and potentially increased survival) alongside those that matter to clinicians and health systems (eg, acute care utilization and hospital readmissions) align around specialty palliative care. There no longer is any reasonable assertion of equipoise regarding the benefit of specialty palliative care services in routine oncology care.

Second, the guidelines remind us that dedication — “the act of devoting wholly and earnestly” — to the physical, emotional, cultural, social, psychological, spiritual, existential, legal, financial, informational and planning needs of serious cancers is our collective responsibility.

Further, the rededication of efforts to focus on quality-of-life issues is even more important in an era of unprecedented change. Health care reforms, along with significant anticipated changes with a new presidential administration, herald a future of shifting rules and regulations governing quality and payment.

Additionally, the extraordinary expansion of the cancer treatment armamentarium adds further complexity to cancer care delivery.

For example, the FDA approved 17 new treatment or supportive care drugs for cancer in 2015. These innovations will require oncologists to learn: 17 treatment regimens, including dose, frequency, administration route and treatment sequence; up to 30 indications for use; knowledge of at least 35 new major clinical trials; and mastery of 85 important side effects.

Attention to the typical concerns of new medications — such as formulary coverage, preauthorization, and evolving methods to address new or novel side effects — adds even more responsibility to the oncology team’s plate. Dedication to palliative care needs of patients with advanced cancer is critical, and yet oncology teams face challenges from multiple angles to deliver this care alone.

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Along with the increasing calls for palliative care integration in routine oncology care, there is a need to address the existing challenges in palliative care delivery. These include the gaps in availability of specialty palliative care services to oncology teams, especially in the community. Although more than 90% of National Comprehensive Cancer Network members indicate an outpatient palliative care program, data outside large academic programs show an accessibility rate of less than 25%.

Further, the panel recommends integration of interdisciplinary palliative care services, defined by the TJC — formerly The Joint Commission — to include a physician, nurse, social worker and chaplain.

Data from the National Palliative Care Registry demonstrate that less than 25% of palliative care programs are resourced to incorporate all four professionals on their team. The specialty of palliative care has come a long way in its growth and acceptance, but key issues remain to be solved.

The new guidelines remind us that palliative care is a foundational component of comprehensive cancer care delivery. Our dedication to quality of life must be unwavering, incorporation of specialty palliative care clinicians must occur often, and continuing challenges in meeting these goals must be addressed. Our patients deserve no less.

References:

Calton BA, et al. J Natl Compr Canc Netw. 2016;14:859-866.

Clough JD, et al. J Oncol Pract. 2015;doi:10.1016/j.jpainsymman.2015.10.016.

Hui D, et al. J Natl Compr Canc Netw. 2016;14:859-866.

Kamal AH, et al. Ann Intern Med. 2015;doi:10.1001/jama.2016.6491.

Kamal AH, et al. JAMA. 2016;doi:10.1001/jama.2016.6491.

Smith TJ, et al. J Clin Oncol. 2012;doi:10.1200/JCO.2011.38.5161.

Spetz J, et al. Health Aff (Millwood). 2016;doi:10.1377/hlthaff.2016.0113.

For more information:

Arif H. Kamal, MD, MBA, MHS, is assistant professor of medicine in the department of medicine at Duke University School of Medicine, as well as member of Duke Cancer Institute. He can be reached at arif.kamal@duke.edu.

Disclosure: Kamal reports no relevant financial disclosures.