Palliative care continues to be an important topic in oncology practice. The latest provisional clinical opinion (PCO) from the American Society of Clinical Oncology (ASCO) recommends offering palliative care to all patients with metastatic or advanced cancer early in the disease process, ideally at diagnosis.1 The evidence for introducing palliative care at the time of diagnosis is strongest for metastatic lung cancer, the leading cause of cancer deaths worldwide.2 However, the PCO from ASCO states that early palliative care can be helpful for patients who have a high burden of symptoms related to other types of cancer as well.3
DISTINCT FROM END-OF-LIFE CARE
Many people still consider palliative care as synonymous with hospice, care. Palliative care comprises hospice among other modalities; however, it is more comprehensive. ASCO defines palliative care as care “focused on the relief of suffering, in all of its dimensions, throughout the course of a patient’s illness.”1 Although there has been increasing use of hospice and other palliative care services at the end of life, many patients are not able to derive proper benefits from these services because hospice is usually not involved until death is less than 3 weeks away.
The ASCO panel noted that providing palliative care along with standard cancer treatment as early as possible in a patient’s illness ensures better outcomes for the patient and the caregiver as the illness progresses. Palliative care improves the course of the disease in a number of ways. It minimizes a patient’s symptoms, increases his or her quality of life (QOL), and improves overall satisfaction. Palliation also reduces the caregiver burden and leads to more effective use of hospice. Furthermore, when introduced at the time of diagnosis, palliative care leads to a decrease in the use of intensive care, to which oncology staff often resort in a fruitless attempt to lend comfort to the dying patient.1
PALLIATIVE CARE IS VALUABLE AT TIME OF DIAGNOSIS
In advanced cancer, “the data are increasingly showing us that palliative care can be incredibly valuable for patients and their caregivers from the time [of diagnosis], not just at the end of life,” according to Jamie Von Roenn, MD. She is a co-author of the ASCO guidelines and professor of medicine in the division of hematology/oncology at the Feinberg School of Medicine, Northwestern University, and the Robert H. Lurie Comprehensive Cancer Center in Chicago, Illinois.4
The ASCO panel analyzed data from seven recently published randomized, controlled clinical trials that comprised patients with metastatic cancer who received both standard cancer care and palliative care. The trials demonstrated that concurrent palliative care for patients with advanced cancer maintains or improves survival and quality of life. In addition, most studies show that these improved outcomes are achieved with a lower financial burden than standard oncologic care alone. However, no trials have demonstrated harm to patients and caregivers, or have delineated excessive costs, as a result of early utilization of palliative care.3
“Preserving quality of life is of utmost importance for all patients,” said PCO co-author Tom Smith, MD, Professor of Oncology and Director of Palliative Care at Johns Hopkins School of Medicine in Baltimore, Maryland. Smith stated in the report that we now have strong evidence that combining palliative care with standard cancer treatment in cases of metastatic cancer improves patients’ lives in many ways, and in some cases, can help extend their lives. “Patients deserve to have access to palliative care services and specialists throughout the course of their care,” Smith concluded.4
KNOWLEDGE GAPS STILL REMAIN
The PCO panel noted that practical considerations that limit the implementation of early palliative care for patients with advanced cancer still exist, even though a growing body of evidence demonstrates its advantages for such patients. For example, reimbursement for early palliative care is not consistently available for patients undergoing active cancer therapy unless they are being treated as inpatients or are enrolled in hospice care as outpatients.
Other “important gaps in knowledge,” according to the PCO panel, call for future research to address them. Subjects yet to be covered include which palliative care interventions have the greatest impact and integration of palliative care into standard cancer care for other types of metastatic and advanced cancer. ONA
Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey.
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. 2012;30(8):880-887.
2. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2009. CA Cancer J Clin. 2009;59(4): 225-249.
3. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
4. New ASCO clinical guidance recommends expanded use of palliative care for patients with metastatic cancer and high symptom burden. American Society of Clinical Oncology Web site. http://www.asco.org/ASCOv2/Press+Center/Latest+News+ Releases/ASCO+News/New+ASCO+Clinical+Guidance+Recommends+Expanded+Use+of+Palliative+Care+for+Patients+with+ Metastatic+Cancer+and+High+Symptom+ Burden. Accessed April 16, 2012.