Palliative care along with standard care is more beneficial

ASCO has released a provisional clinical opinion (PCO) addressing the integration of palliative care services into standard oncology care.¹ The ASCO Post recently spoke with one of the PCO’s lead authors, Thomas J. Smith, MD, Director of Palliative Care for Johns Hopkins Medicine and the Johns Hopkins Sidney Kimmel Cancer Center, Baltimore.

Central Message

What is the central message of the ASCO provisional clinical opinion on palliative care?

The provisional clinical opinion highlights new clinical information that””in the context of previous data””really changes standard practice. Over the past several years, we’ve seen an increasing number of randomized controlled trials that basically come to the same conclusions about palliative care interventions: They do no harm and typically result in better quality of life, better symptom management, less depression and anxiety, less distress among caregivers, and more honoring of patients’ choices about events near the end of life.

The Temel et al lung cancer trial² was the latest randomized trial confirming the benefits of introducing palliative care concurrent with standard oncology care. Patients in the palliative care intervention arm understood their treatment and prognosis better than those receiving standard care alone. They used less IV chemotherapy in the last 60 days of life, used hospice services more often and longer (longer is better), and lived almost 3 months longer than patients receiving standard care alone.

The success of the Temel study isn’t magic. It boils down to this: Having another group of health-care professionals [in addition to treating oncologists] focusing on patient symptoms and discussing goals and treatment options turns out to be very useful and highly desired.

Difference of Opinion

The NCI’s Physician Data Query (PDQ) editorial board acknowledged the successes in the studies of palliative care intervention, but concluded that given the scant amount of data, it is premature to develop a provisional clinical opinion. What is your reaction to that review?

PDQ is known to be very conservative. Although they looked at a number of trials, some of them were 10 years old, and they weighed those investigations as heavily as more recent studies. For example, in two trials they reviewed, less than one-quarter of the palliative care recommendations were followed. So it’s hard to discount the value of palliative care when it was hardly ever used. That’s like saying radiation therapy didn’t work, but only one of four patients received it.

Knowing the field, and knowing the importance of an interdisciplinary palliative care team, our group concluded that the evidence supporting palliative care was increasingly compelling. We also know that we currently don’t have enough palliative care specialists. But when lumpectomy plus radiation therapy became the preferred treatment for breast cancer, we didn’t wait to make that pronouncement until everyone had access to a team that could provide the therapy. We know that we have to stimulate demand in the field as well as give physicians like me the opportunity to learn new skills.

Hospice/Palliative Care Synergy

Hospice is part of palliative care. However, hospice programs will not cover chemotherapy, radiotherapy, and supportive care drugs, which disengages the valuable hospice/palliative care synergy. Is this something that can be addressed?

This is the situation in nearly all communities, whether large or small, academic or not. Hospice is an integral part of palliative care, and palliative care has moved many of the core concepts of hospice into the hospital and sometimes upstream. We appreciate that nearly all hospices do not cover chemotherapy, radiation, or supportive care drugs””they simply cannot, on a per diem reimbursement of $130 to $150.

But there are and will be more programs that cover “concurrent” palliative treatments and hospice. Aetna’s Compassionate Care Program and similar programs have an “expanded access” option that increasingly will let people enroll in hospice but not have to give up all treatment. The insurers know that they will save money by improving care at home, and that most people will elect not to die in the hospital, especially in the intensive care unit. And this is really honoring patients’ choices, once we make them known.

There are also positions that ASCO members can take to help the process. We can have our patients talk with hospice for an informational visit when they have 3 to 6 months left to live. This brings the hospice group into the picture as part of the same team, lets them know the patient, and makes transitions easier.

We can also have the “hard conversations” earlier. Data from the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study””conducted mostly in community settings””showed that 60% of medical oncologists prefer not to have discussions about “do not resuscitate” orders, advance medical directives, or hospice until there are no treatment options left.³ No one mentioned hospice to half the patients with lung cancer within 2 months of their death. Getting hospice involved, as part of “best practice” in the continuum of care, is something we can control.

Closing Thoughts

Any last thoughts about this issue?

It is an incredibly important point to make that palliative care is all about honoring peoples’ choices. The only way to do that is to bring up the hard issues early and often in quality discussions. All the data show that when doctors have honest conversations with patients who are seriously ill, the quality of remaining life for patients and their families is far better. â– 

References

1. Smith TJ, Temin S, Alesi ER, et al: American Society of Clinical Oncology provisional clinical opinion: The integration of palliative care into standard oncology care. J Clin Oncol. February 6, 2012 (early release online).

2. Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733-742, 2010.

3. Huskamp HA, Keating NL, Malin JL, et al: Discussions with physicians about hospice among patients with metastatic lung cancer. Arch Intern Med 169:954-962, 2009.