The recipient of this year’s American Society of Clinical Oncology (ASCO)/American Cancer Society (ACS) award is a prominent expert in palliative care. Jamie H. Von Roenn, MD, has been practicing in medical oncology for more than 25 years. She is Professor of Medicine in the Division of Hematology/Oncology at Northwestern University’s Feinberg School of Medicine and is medical director of the Home Hospice Program at Northwestern Memorial Hospital. She is also a member of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University and co-director of its Cancer Control Program.
In her Expert Editorial for ASCO 2011, Von Roenn wrote:
Each year in the United States, 30% to 50% of the 1.5 million people diagnosed with cancer, and 70% to 90% of the 500,000 patients with advanced cancer, will experience unrelieved suffering.1,2
These statistics have remained essentially unchanged over 20 years, despite research that demonstrates that 70% to 90% of the suffering associated with cancer and its treatment can be relieved by oncologists with adequate palliative care training.3 In other words, persistent suffering is a result of the failure to translate palliative care knowledge into practice.4
She noted that although palliative care is now accepted as an essential component in the continuum of cancer care, it is not evident that this philosophy has done anything to change the practice of oncology.
WHY HAS NOTHING CHANGED?
“There are at least four reasons why palliative care is not yet part of comprehensive cancer care in the United States,” wrote Von Roenn. “Palliative care is ‘end-of-life’ care; cancer care is either ‘cure’ or ‘comfort’—there must be a transition from curative life-prolonging treatment (without palliative care) to palliative care; the perception among oncologists that they do not need to improve; and inadequate training of oncologists in communication skills, prognostication, and symptom management.”4
Von Roenn advocates for bringing the principles of palliative care into the field of oncology care and cancer pain management. She emphasizes that the treatment of the disease has an effect on both the symptoms of disease and the symptoms of the treatment. Although oncologists treat the nausea and vomiting that are related to cancer therapy, they are often unaware of less obvious symptoms such as depression or fatigue. Treating these symptoms is applying palliative care as well. “Doesn’t every oncologist already provide some level of palliative care? I doubt anyone prescribes cisplatinum without also providing antiemetics. This is symptom prevention. This is one component of palliative care already widely integrated into oncology practice,” she said.
CARE FOR THE PATIENTS AS WELL AS THEIR CANCER
The oncology team should recognize that curing a patient’s cancer is not enough. According to Von Roenn, oncologists have a responsibility to care for the people who have the disease with as much dedication as they do for the cancer itself. “Palliative medicine has come of age,” she said. “Palliative medicine has only recently become a recognized subspecialty in the United States, and its recognition by multiple medical specialties has made the concepts and the unique medical knowledge central to palliative care more visible. For a long time people thought of palliative care as hand-holding, but in fact it’s so much more than that.”
Von Roenn explained that palliative care improves quality of life and controls symptoms, therefore enabling the treatment team to follow through on patient choices. Unfortunately, although doctors may believe that palliative care can be valuable, many are still hesitant to bring it up in conversations with their patients. They are afraid that patients might misinterpret such a conversation as the physician’s lack of commitment to continue treatment. They also fear that a discussion of palliative care will destroy a patient’s hope for recovery.
CONTINUUM OF CARE
According to Von Roenn, “People equate palliative care with the end of life, when in fact it is part of care throughout the continuum. There clearly is a time, not only when patients are dying but when they are cured, when treating the disease isn’t the goal. We should always give good symptom management when people present with disease; if they are cured, we should treat the symptoms of our therapy; if they recur, we should treat the symptoms along with the disease recurrence.”
TREAT THE PATIENT AND THEIR CAREGIVERS
Von Roenn reminded the oncologists that palliative care should be given not just to those who have cancer, but also to those who treat the patients who have cancer. She emphasized that the experience of having cancer affects patients and their loved ones profoundly, and that skills in both palliative care and communication are essential for matching therapy to patient goals. Furthermore, palliative care may be necessary for quite a while, since we now know that effects of the disease and its treatment can last for the survivor’s lifetime. “Symptom burden has a profound effect on quality of life, and currently available symptom management strategies, if widely implemented, could relieve much of this suffering,” she noted. ONA
Bette Kaplan is a medical writer based in Tenafly, New Jersey.
1. Foley KM, Gelband H, eds; Institute of Medicine, National Research Council. Improving Palliative Care for Cancer: Summary and Recommendations. Washington, DC: National Academy Press; 2001.
2. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin. 2010;60(5):277-300.
3. Field MJ, Cassel CK, eds; Committee on Care at the End of Life, Institutes of Medicine. Approaching Death: Improving Care at the End of Life. Washington, DC: National Academy Press; 1997.
4. Dr. Jamie H. Von Roenn, pioneer in palliative medicine, receives ASCO/ACS award. ASCO Daily News. June 3-7, 2011. http://chicago2011.asco.org/ASCODailyNews/ACSAward.aspx. Accessed July 15, 2011.