It has been more than two years since the American Society of Clinical Oncology published its provisional clinical opinion (PCO) on early palliative care, which says that “combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden” (OT 3/25/12 issue).
But oncologists are not all on board. As shown in an Early Release article in the Journal of Oncology Practice (doi: 10.1200/JOP.2013.001130), research conducted at three cancer centers that have well-established outpatient palliative care clinics found that 22 of the 74 medical oncologists interviewed believe that palliative care is an alternative to chemotherapy, rather than complementary care.
The interviews were conducted in 2012; the ASCO Board of Directors approved the PCO in November 2011 and published it in February 2012.
“There is a significant minority of oncologists who feel that palliative care is incompatible with chemotherapy even though that is no longer supported by guidelines,” said the lead author of the JOP study, Yael Schenker, MD, MS, a palliative care specialist at the University of Pittsburgh Cancer Institute (UPCI) in Pennsylvania.
The qualitative study involved oncologists at UPCI, the University of California San Francisco Helen Diller Comprehensive Cancer Center, and Mount Sinai Tisch Cancer Institute.
That fundamental disagreement about the appropriate use of palliative care is one of three barriers to early referrals for palliative care that the researchers identified. The others are:
- The belief that providing palliative care is the medical oncologist's responsibility and should not be referred to a subspecialist; and
- Lack of knowledge about available palliative services or understanding of how and when to make a referral.
“We still have work to do about raising the awareness of palliative care,” Schenker said in an interview. Analysis of the interviews identified several recommendations on ways to improve the use of early palliative care:
- Provider education about available services. (One participant said that simply having the palliative care team introduced at an oncology clinic would improve awareness);
- Provider education about what palliative care means and the benefits to patients. (Some interviewees equate palliative care with hospice or “abandoning” patients); and
- The development and testing of new practice models that allow oncologists and palliative care specialists to collaborate and integrate their work. Some oncologists believe that palliative care is their responsibility and do not want to share the role with other physicians.
“Even at academic cancer centers where palliative care is well established, we find a wide range of oncologists' views about these services,” Schenker said. “Culture does change, but it changes slowly.”