Carlson, Robert H.
A new policy statement by the American Society of Clinical Oncology recommends that physicians begin candid discussions with patients about the full range of palliative care and treatment options soon after a diagnosis of advanced cancer.
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“While improving survival is the oncologist's primary goal, helping individuals live their final days in comfort and dignity is one of the most important responsibilities of our profession,” said ASCO President George W. Sledge, Jr., MD, in introducing the statement. “Patients have a right to make informed choices about their care, and oncologists must lead the way in discussing the full range of curative and palliative therapies to ensure that patients' choices are honored.”
The statement says that delivery of palliative care along with cancer-specific care not only improves quality of life, especially in terms of mood and prevalence of major depression, but also significantly reduces the need for hospitalization.
And recent data cited in the statement show that palliative care can prolong survival. That was from a randomized, controlled trial in which patients with advanced lung cancer who received both chemotherapy and palliative care immediately after diagnosis lived almost three months longer than those who received chemotherapy alone (Temel, Greer, Muzikansky, et al: NEJM 2010;363:733-742).
Along with the statement, ASCO also released a guide to help patients broach difficult conversations with their physicians about prognosis, treatment, and palliative care options. And later this year, the society said, the plan is to issue its first clinical guidelines on how to initiate these conversations.
“For many with advanced cancer, conversations about palliative and hospice options do not occur until the patients' final weeks or days of life, if they happen at all,” Dr. Sledge said. A preliminary analysis of 5,500 patient records from ASCO's Quality Oncology Practice Initiative (QOPI) shows that only 45% of cancer patients are enrolled in hospice care before death, one-third of whom were enrolled in the last week of life.
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No Abrupt Transitions
The first author of the ASCO statement, Jeffrey Peppercorn, MD, Associate Professor of Medicine at Duke University Medical Center, said the authors felt it important to broaden the conversation, and move away from a model that emphasizes disease-directed therapy until very late in the course of illness and then abruptly transitions to focus on end-of-life issues.
“Instead, we encourage oncologists and patients to discuss prognosis and options throughout the course of illness, and to develop a plan for disease-directed and palliative or supportive therapy that best matches the patient's goals, the unique circumstances of their disease, and its impact on the patient's quality of life,” Dr. Peppercorn said, in an e-mail exchange.
He acknowledged that there may be limited time available for these discussions during a typical clinic visit, but said that this is precisely why highlighting the potential value of these conversations is so important. Dr. Peppercorn said that ASCO has a number of initiatives under way through the society's Cancer.Net patient website and other venues to promote conversations about prognosis, goals of care, and options to empower patients. And physicians can gain competence and confidence in their ability to discuss these issues through educational initiatives in training and CME, skills he says are not always taught in oncologic training.
In addition, he said, in terms of a practical, business matter, oncologists should be reimbursed for the time required for these conversations about complex issues and choices.
Diane Meier: Good to be Acknowledging the Deficit in Practice
Asked to comment on the ASCO statement for this article, Diane E. Meier, MD, Director of the Center to Advance Palliative Care and Director of the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine, said that ASCO is to be commended for acknowledging that there is a deficit in how oncology is practiced today, and that it needs to be corrected.
She said the statement strengthens ASCO's earlier positions by encouraging oncologists to recognize that comprehensive care focuses not only on diseases and treatment, but also on quality-of-life.
“It shouldn't really surprise us that reducing patients' misery helps them live longer,” she said in a telephone interview.
Dr. Meier said the idea that palliative care can extend survival in cancer patients may seem counter-intuitive to oncologists and to other subspecialists such as cardiologists.
“We physicians are trained to do things a certain way, and whatever we were not trained in, we don't do. So an oncologist who's basically trained to give chemotherapy for cancer and doesn't understand that other modalities, including palliative care, are really important to the health and well-being of the patient, won't deploy those resources because it wasn't in their training.”
Don't Confuse Palliative Care & Hospice
Dr. Meier did, though, have a strong objection to one aspect of the ASCO statement, saying that it should not have included discussions about palliative care and end-of-life in the same document.
Hospice care is for patients who are clearly dying, she said, and not for people living with a serious chronic illness who are not eligible for hospice because they're still benefiting from life-prolonging treatment.
“That's where the gap is, and I think that to the extent that this report unfortunately linked palliative care to end-of-life care, many people will be afraid to ask for it,” she said. “And to the extent that they think you're giving them palliative care because you're preparing them for death, they don't want any part of it.”
She said it is a very confusing message and it might have been addressed somewhat differently. Nonetheless, she said, the overarching message to the members of ASCO is a very important step forward—that “oncologists in practice can no longer afford to think that palliative care is somebody else's job.”
Asked about this critique, Dr. Peppercorn said some people have focused on the fact that one of the statement's recommendations is to ensure a transition to palliative care once evidence-based options have been exhausted.
“Overall, I agree that the issue is less about end-of-life care and more about how we treat patients and provide them the full range of evidence-based options, including palliative care and disease-directed therapy, throughout their illness,” he said.
“The statement itself does not focus on hospice or end-of-life care, but it does focus on the need to step out of the mode of only considering one line of disease-directed therapy after another, and to ask ourselves and our patients: what are the patient's goals; what are the options; are we adequately addressing quality of life; and how should we balance disease-directed and palliative care moving forward?”
Dr. Peppercorn said he understands the concerns raised by the palliative care community about associating palliative care with end-of-life care, “but they miss some of the point—that the statement's target audience includes oncologists who are not using an individualized approach and are likely never discussing these issues with patients, or not until very late in the course of illness.”
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Make Time for Discussion
The Chief of the Pain and Pal-liative Care Service at Memorial Sloan-Kettering Cancer Center, Paul A. Glare, MD, strongly endorsed the statement.
But he added that ASCO should not minimize the problem of making time for these discussions with patients.
Fitting time into an oncologist's schedule to discuss palliative care is no small matter, Dr. Glare said.
“It does take a lot of time, it's challenging, and it's very draining,” he said.
Although time available for office visits is limited, Dr. Glare said many patients with advanced cancer are fragile and some travel long distances, making it difficult for them to return to the cancer center to discuss possible palliative options.
“Time must be found for them while they're here,” he said, noting that Memorial Sloan-Kettering has a palliative care clinic in midtown Manhattan (at 53rd Street) open six days a week, where physicians can get help about informing patients about palliative care options.
Dr. Glare agreed with Dr. Meier on the importance of separating palliative care from hospice.
“Palliative care is for people who've got advanced cancer that's probably not curable and they're going to die from it,” Dr. Glare said. “And while they're having their disease-controlling treatment, even though their disease can't be cured, hopefully it can be controlled, and at the same time they want to have their symptoms controlled.”
That said, he does believe that for some selected patients it is appropriate to discuss palliative care and hospice together, while for others it is important to explain that palliative care is not the same as hospice.
Dr. Glare also thought it important to distinguish between palliative care that an oncologist ought to be able to provide, and what is needed in the more complicated, time-consuming cases when a palliative care specialist can help the oncologist with symptom control, psychosocial issues, and family support.
And if the patient is dying, the specialist can help the transitioning to hospice.
“It's an important part of palliative care to recognize when the time has come and assist with the transition” to hospice care, he said.
The ASCO Statement, “Toward Individualized Care for Patients with Advanced Cancer,” was published online in JCO on January 24 (doi: 10.1200/JCO.2010.33.1744). The 24-page patient brochure, “Advanced Cancer Care Planning: What Patients and Families Need to Know about Their Choices When Facing Serious Illness,” is available at http://www.cancer.net/patient/Coping/Advanced+Cancer+Care+Planning
Resources & Training
For oncologists in practice who want additional training and skill in palliative medicine, Dr. Diane Meier recommended the Board Review course given by the American Academy of Hospice and Palliative Medicine (AAHPM).
Even a physician not taking the Boards can get some immersion content, she said.
Also, Harvard University Medical School gives an annual conference on clinical aspects of palliative medicine for non-palliative medicine physicians.
And on-line courses are available through EPEC.net (Education and Palliative and End-of-Life Care). Both oncologists and their patients can find palliative expertise in their neighborhood through getpalliativecare.org, a provider directory, Dr. Meier said.
© 2011 Lippincott Williams & Wilkins, Inc.