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"Palliative Care and Oncology: A Review"

Sara Martin1*, Maie El-Sourady2 

1Medical Director Outpatient Palliative Care Vanderbilt Medical Center, USA

2Division of Internal Medicine and Palliative Care, Vanderbilt University Medical Center, USA 

*Corresponding author(s): Sara Martin, Medical Director Outpatient Palliative Care Vanderbilt Medical Center, USA. Tel: +1-6159361212; Email: sara.martin@vumc.org

Maie El-Sourady, Division of Internal Medicine and Palliative Care, Vanderbilt University Medical Center, USA. Tel: +1-6153224298; Email: maie.el-sourady@vumc.org 

Received Date: 30 August, 2018; Accepted Date: 15 November, 2018; Published Date: 21 November, 2018

Palliative care is a medical specialty that provides care for patients living with a serious illness. In recent years, there has been a growing body of evidence supporting early specialist palliative care for patients with advanced cancer. This review focuses on the current evidence that supports improved patient outcomes for patients with cancer that receive early specialist palliative care. Further, there is discussion of real limitations to far reaching access of this care and opportunities for improvement and further partnership to improve the lives of all patients and caregivers facing a diagnosis of advanced cancer.

Introduction

Palliative care is a medical specialty that provides care for patients living with a serious illness. Palliative care focuses on providing relief from the symptoms and stress of living with a serious illness while working to improve quality of life for patients and their caregivers [1]. Over the past two decades, acceptance and demand for palliative care services has increased, raising questions as to which skills should be expected of all clinicians who care for seriously ill patients and those skills that require the expertise of specialists who have undergone advanced training in palliative care. Quill and Abernethy [2], have proposed that primary (also called generalist) palliative are skills should include basic management of burdensome symptoms as well as basic discussions of prognosis and goals of treatment. They propose that specialist palliative care, which is often delivered by an Interdisciplinary Team (IDT) with advanced training in palliative care, can assist with refractory symptoms, conflict resolution surrounding treatment goals, and with existential suffering [2]. Oncologists guide their patients through extraordinarily challenging times, discussing difficult decisions, managing symptoms, and using primary palliative care skills to support patients and their families through their journey [3]. Over the past several years, a growing body of evidence has shown that specialist palliative care significantly benefits patients with advanced cancer. We review the evidence of the impact of specialist palliative care on oncology patients and discuss the challenges and opportunities of incorporating both primary palliative care and specialist palliative care into the care of oncology patients. 

Specialist palliative care improves symptom management for patients with advanced cancer. Zimmerman, et al. [4] conducted a large cluster-randomized controlled trial of patients with advanced solid tumor cancers that showed patients who received early specialist palliative care had significant reduction in symptom burden as measured by the Edmonton Symptom Assessment Scale compared with patients receiving standard care (-1.34 vs. +3.23; p=0.05) [4]. Temel, et al. [5] randomized patients with metastatic non-small-cell lung cancer to receive specialist palliative care at the time of diagnosis compared to standard care, and demonstrated that patients receiving early specialist palliative care had less depressive symptoms based on the Hospital Anxiety and Depression Scale compared to patients receiving standard care (16% versus 38%, P=0.01) [5]. 

Specialist palliative care has shown an improvement in quality of life for patients with advanced cancer and their caregivers in several studies. Bakitas, et al. [6] randomized patients with advanced cancer (gastrointestinal, breast, lung, and genitourinary) to early specialist palliative care versus standard care in the ENABLE II study. Patients receiving specialist palliative care had better quality of life per the Functional Assessment of Cancer Therapy - Palliative Care Scale (mean difference of 4.6, P=0.02) [6]. Temel, et al. [5] showed improvement in quality of life in patients with metastatic non-small cell lung cancer who received specialist palliative care at diagnosis, reporting scores of 59.0 vs. 53.0 (P=0.009) on the Functional Assessment of Cancer Therapy - Lung Scale after 12 weeks [5]. In patients with advanced solid tumors, Zimmerman, et al. [4] showed improvement in quality of life at three months in those patients receiving specialist palliative care compared with those receiving standard care per the Quality of Life at the End of Life Scale (2.33 vs. 0.06; p=0.05) [4]. 

Several studies have also shown a survival benefit for oncology patients that receive early specialist palliative care. Temel, et al. [5] showed that patients with metastatic non-small cell lung cancer who received specialist palliative care at diagnosis lived almost 3 months longer and had less aggressive end of life care than patients who received standard care (median, 11.6 vs. 8.9 months; p=0.02) [5]. The ENABLE III study found that patients with advanced cancer who receive early specialist palliative care had longer 1year survival rates than patients receiving specialist palliative care 3 months later in their treatment course (63% vs 48%; p=.038) [7]. 

The landscape of cancer care is constantly changing with immunotherapy and disease targeted therapy becoming more available for many cancer types. Einstein, et al. [8] studied the effect of an embedded specialist palliative care service in an academic oncology clinic that specialized in immune-based therapies and found that patients in the embedded model had a longer duration of time on hospice (mean, 57 vs. 25 days; p=0.006) as well as higher enrollment in hospice greater than 7 days prior to death, a core Quality Oncology Practice Initiative Metric (odds ratio, 5.60; p-0.034) [8]. This finding suggests that even as therapy options evolve for patients with advanced cancer, palliative care remains an important component of their care. 

Adding additional medical team members has the potential to increase confusion for patients, families, and the medical team, especially when there is the potential for overlapping roles of different providers. Hannon, et al. [9] conducted a study of semi-structured qualitative interviews of patients and caregivers under the care of an oncologist and specialist palliative care physician or team [9]. In their conclusions they state “participants perceived the respective roles of their oncologist and palliative care physician as discrete, important, and complementary for the provision of excellent cancer care [9].” This study suggests that both services, when medically necessary, provide distinct and complementary aspects of care that combine to provide a more patient-centered care plan with improved outcomes. In an editorial, Huillard, et al. [10] discuss a series in which a dedicated weekly oncology-palliative care meeting independently decreased the odds of receiving chemotherapy in the last 14 days of life and of dying in the acute setting [10]. Based on these findings, the authors suggest that shared decision-making between oncologists and the specialist palliative care team should be considered an indicator of integration of the two services [9], raising the hope that increased and ongoing communication between both oncology and specialist palliative care teams will improve patient-centered outcomes. 

The American Society of Clinical Oncology (ASCO) [11,12], the National Comprehensive Cancer Network [13], and the Commission on Cancer of the American College of Surgeons [14] have called for the integration of palliative care into standard oncology care for all patients with advanced cancer. Although a growing body of research shows the benefits of early specialist palliative care, there remains little guidance on how and when to provide palliative care for these patients. Most studies of the effect of early palliative care reflect the addition of specialist palliative care for patients with advanced cancer treated in academic centers, which does not encompass the experience of all patients with advanced cancer. An important question will be how to incorporate the elements of excellent palliative care in patients that are not treated in an academic medical center or who have limited access to specialist palliative care. 

In addition to the issue of resource allocation, another issue that remains is the exact timing and method of initiating specialist palliative care consults for patients with advanced cancer. In a prospective, multicenter, randomized controlled trial, Maltoni, et al. [15] randomized patients with a new diagnosis of metastatic pancreatic cancer to systemic specialist palliative care consultation (automatic consult request based on diagnosis) compared to on-demand specialist palliative care consultation (consultation request at the discretion of the primary treatment team). Patients who had systemic specialist palliative care had improved quality of life based on a difference between groups in the Trial Outcome Index (TOI) of 6.35 (95% CI 0.75 to 11.95) (p = 0.022) [15]. The TOI was obtained by combining the scores of physical, functional, and disease-specific subscales based on patients responses to the Functional Assessment of Cancer Therapy - Hepatobiliary scale (FACT-Hep) and Hepatobiliary Cancer Subscale (HCS) [15]. This study suggests that systemic specialist palliative care consultation may be a better way to improve quality of life in patients with advanced cancer than on-demand specialist palliative are consultation. 

Given the growing body of evidence that demonstrates improvement in symptoms, quality of life, survival, decreased aggressive care at the end of life, and increased timely hospice utilization, specialist palliative care will continue to be an increasingly important part of comprehensive cancer care for patients with advanced disease. The landscape of cancer care is rapidly changing, which will necessitate ongoing research into the optimal timing and integration of palliative care. This expanding need must be balanced with the issues of work force stress and geographic variations making the need for primary palliative care by oncologists increasingly important. A comprehensive approach to incorporation of palliative care for patients with advanced cancer may include expanding skills-based primary palliative care training for medical trainees and practicing oncologists, identifying patients that would benefit from early specialist palliative care, and improving delivery systems to ensure that all patients with advanced cancer have excellent primary palliative care and access to specialist palliative care [16]. As the treatment options for advanced cancer change and expand, it is easy to envision an increasing complexity in medical decision making and an increase in patients living longer lives with symptom burden. To increase access to palliative care for patients where these services exist, healthcare systems will need to reconsider the current model of on-demand palliative care consultation to a more systemic integration of palliative care services. The opportunity to find comprehensive and innovative ways to integrate palliative care services into the care of oncology patients promises to be an exciting and fruitful partnership for the oncology and palliative care medical communities as well as oncology patients and their loved ones.



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Citation: El-Sourady M, Martin S (2018) Palliative Care and Oncology: A Review. Arch Palliat Care Med: APCM-110. DOI:10.29011/APCM-110.00010

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