Palliative Care and Oncology: Integration Leads to Better Care
The timely integration of palliative care services into standard oncology care is essential to providing comprehensive individualized care for patients with advanced and incurable cancer and their families. Herein we discuss five important areas in which this integration is critical to optimize management, namely: symptom management, transitioning from disease-focused care to palliative care, discussing goals of care and advance care planning, community care, and psychosocial support for the patient and family.
Patients with advanced progressive cancer require care plans that address their physical, emotional, and psychosocial needs, as well as their goals of care. However, it is difficult for oncologists working in isolation to properly identify these needs and deliver comprehensive care. In the past, patients and physicians generally considered oncology and palliative care to be mutually exclusive domains, with the latter being reserved only for the end of life, when all disease-modifying therapy had ceased. It is now accepted that integrating the two earlier in the course of a patient's disease can lead to improvements in symptom control; quality of life (QOL); patient and family satisfaction with care; and the coordination, efficiency, and effectiveness of services provided.
Given the projected rise in prevalence of patients with incurable cancer in the coming years, an ideal model of sustained collaboration between oncology and palliative care could provide appropriate, timely, comprehensive, and cost-effective care. There are five key components of patient care in which such cooperation is especially important: symptom management, transitioning from disease-focused care to palliative care, discussing goals of care and advance care planning, community care, and patient and family psychosocial support.
In recent years, anti-cancer therapies have proven more effective at prolonging life in patients with incurable cancer. An unfortunate consequence of this progress has been a longer duration of time during which patients are at risk of symptoms from complications related to the disease and its treatment. With this in mind, evidence-based and multidisciplinary strategies for assessing and managing symptoms in this population are critical to providing effective care in hospital, outpatient, and home-based settings.
Patients with advanced cancer suffer from a range of symptoms throughout the course of their disease. Metastases are often first confirmed after new symptoms develop, and as the distribution of disease changes with time, so does the character of the symptom experience. Patients develop local symptoms such as pain, bleeding; obstruction and dysfunction as a result of macroscopic primary or metastatic lesions; biochemical disturbances caused by systemic changes or paraneoplastic syndromes; and more general constitutional symptoms such as malaise, cachexia, and fatigue, as a result of overall disease progression. Investigations and treatments also lead to symptoms and complications, as patients commonly undergo biopsies, surgery, chemotherapy, and radiotherapy. Polypharmacy may become a concern as well, especially in the elderly.
Symptom management needs to be a key focus at all times for practitioners caring for these patients, and a strategy of prevention rather than reaction should be employed. Unfortunately it is challenging for oncologists to continuously and rigorously evaluate all of their patients, especially those presenting with multiple symptoms which may or may not be related to their cancers or treatments.
Comprehensive assessments and treatment plans that are delivered by teams of care providers including palliative care professionals, and which address the full range of symptoms, should provide the obvious benefit of superior symptom relief. They have also been shown to improve QOL and other patient-reported outcomes, and to have an impact on survival. A recent single-center non-blinded randomized controlled trial involved ambulatory patients with good performance status within 8 weeks of being diagnosed with metastatic non–small cell-lung carcinoma. It compared the early integration of a palliative care program with standard oncologic care vs standard oncologic care alone. In this trial, Temel and colleagues designed their palliative care program by adapting a model from the National Consensus Project for Quality Palliative Care, and patients randomized to this intervention met with board-certified palliative care physicians and advanced-practice nurses within 3 weeks of enrollment, and then monthly afterwards until death. At 12 weeks, patients receiving the intervention had a significantly improved symptom profile as measured by the mean change in a trial-specific self-reported QOL score that represented the sum of scores on the LCS (lung cancer subscale) of the FACT-L (Functional Assessment of Cancer Therapy–Lung) scale and the physical well-being and functional well-being subscales of the FACT-L scale. Surprisingly they also showed a significantly longer survival time of 11.6 months for the palliative care intervention group, vs 8.9 months for patients with standard care. The authors hypothesized that the improved survival may have been due to better symptom management leading to clinical stabilization, but they and others rightly note that further study is needed to validate their findings and test such a hypothesis.[2,5,6] Other randomized studies of inpatient, outpatient, and home-based palliative care interventions for patients with cancer have shown mixed results with respect to physical symptom improvement, and it has been suggested that programs may require clinic-based and face-to-face components to effectively palliate physical symptoms.
However, this emphasis on collaborative programs is not to suggest that effective symptom management can only be provided by specialized palliative care services and experts. Oncologists and primary care physicians possess the basic skills and competencies to assess and manage most symptoms experienced by patients. Their jobs can be made easier by use of evidence-based algorithms for assessment and treatment, checklists, patient and practitioner education and evaluation, and continuous quality improvement supported by consulting palliative care personnel as necessary. Referrals to specialized palliative care services (eg, secondary or tertiary services) are necessary for cases of complicated, multiple, or refractory symptoms, or for opinions on effective prevention strategies prior to implementing treatments or transitioning patients from one setting to another.