Oncologists Must Discuss All Options in Advanced Cancer: ASCO Policy

Zosia Chustecka

January 28, 2011

January 28, 2011 — A new policy statement from the American Society of Clinical Oncology (ASCO) aims to improve communication with, and decision making for, patients with advanced cancer (defined as incurable disease).

It calls for a change in paradigm for advanced cancer care and a new approach in which all available treatment options are discussed from the very beginning.

The statement was published online on January 24 in the Journal of Clinical Oncology.

"While improving survival is the oncologist's primary goal, helping individuals live their final days in comfort and dignity is one of the most important responsibilities of our profession," ASCO president George Sledge, MD, said in a statement.

"Oncologists must lead the way in discussing the full range of curative and palliative therapies to ensure that patients' choices are honored," he said.

New Paradigm of Care

This new approach "requires stepping back from the paradigm of applying one line of therapy after the other and focusing primarily on disease-directed interventions," say the authors, comprised of a panel of oncologists and specialists in palliative care.

"Instead, we need to move toward developing a treatment plan that is consistent with evidence-based options (including disease-directed and palliative care), and the patients' informed preferences for how we pursue and balance these options throughout the course of illness," they add.

Conversations about all of the options that are available must be started earlier, and they must be more thorough, the panel insists.

"These conversations should be going on throughout the course of the patient's illness," lead author Jeffrey Peppercorn, MD, PhD, medical oncologist at Duke University in Durham, North Carolina, said in an interview.

A lot of the press coverage about this new initiative has focused on end-of-life care; this is a mistake, he said. "That is involved, of course, but the main point is to begin these conversations early on, when the patient is first diagnosed, and then continue the dialogue at regular intervals throughout the illness."

"We know that patients with advanced cancer have many different treatment options, and often the focus is — appropriately — on disease-directed therapy and what will work best to treat the cancer," explained Dr. Peppercorn.

"But we need to remember the patients' symptoms and their preferences, and strike the right balance between disease-directed and supportive therapy," he continued. The early involvement of palliative care might not only improve symptoms and quality of life but, at least in one study, it also improved survival, he pointed out.

"We must remember to treat the patient and not just the cancer," he added.

Candid Conversations

The policy statement outlines step-by-step recommendations to ensure that physicians initiate candid discussions about the full range of palliative care and treatment options soon after a patient's diagnosis. ASCO will follow this up with a clinical guidance document later in the year, and there will be several educational sessions on this topic at the annual meeting.

As a complement to this initiative, ASCO has released a guide for patients with advanced cancer to help them broach difficult conversations about their prognosis, treatment, and palliative care options with their physicians.

"Candid conversations are key," Dr. Peppercorn and colleagues write. "Physicians should initiate candid discussion about prognosis with their patients soon after an advanced cancer diagnosis."

However, recent studies suggest that such conversations currently occur in less than 40% of cases.

The authors acknowledge that these conversations are inherently difficult and uncomfortable, but point out that delaying them will only heighten the problem.

"We know that these conversations are difficult, but without them, patients may end up receiving disease-directed care even when there is no realistic chance of benefit, sometimes right up to the last few days of life," Dr. Peppercorn told Medscape Medical News.

Stopping Anticancer Therapy

Some of the statements in the document appear to be giving permission for both doctors and patients to stop specific anticancer therapy.

"As a guiding principle, anticancer therapy should be considered only when it has a reasonable chance of working and providing meaningful clinical benefit," according to the document. "Oncologists should feel no obligation to provide an intervention that clinical evidence and the clinician's best judgment suggest will provide no meaningful benefit to the patient and may cause harm."

"That is definitely part of it," explained Dr. Peppercorn. "For both doctors and patients, it's very hard to step back from the focus on disease-directed therapy . . . . We hope that this new initiative will give permission, and also courage, to both sides to have these very difficult conversations, and will highlight the benefits of having these conversations."

"Instead of viewing the whole process as fighting, fighting, fighting, and then giving up," he said, "having these conversations as an ongoing dialogue may lead to better outcomes for the patients. In some instances, stopping cancer therapy may be in the patient's best interest; they may have a better quality of life for the time they have remaining."

This can be difficult for oncologists, with their focus on treating cancer, because stopping that treatment can be perceived as a failure. "We want to emphasize the notion that we can continue aggressive treatment of the patient, and instead of focusing on the cancer, we can focus on symptoms through palliative care," he explained.

"There is no one correct way of doing this, or one best approach that is appropriate for all patients," Dr. Peppercorn said. This policy document outlines steps that can be followed, but each patient will need an individualized approach, depending on the individual circumstances.

More Time Involved

One of the barriers to implementing this vision of individualized care for patients with advanced cancer is the time involved.

"Engaging in discussions of prognosis, options, and the patients' goals and preferences requires substantially more time than is commonly allotted for the standard follow-up visit," the authors write.

"In addition, the current reimbursement system strongly favors intervention over prolonged discussion," they point out. "There is a misalignment of incentives in the current healthcare system that inadvertently encourages administration of cancer-directed treatment at the end of life, rather than the time-consuming, emotionally challenging discussions that emphasize candor, comfort, family, and quality of life."

"Efforts to compensate oncologists and others for delivering this important aspect of cancer care were unfortunately politicized in the recent healthcare reform debates," the authors note. However, these efforts had at their core a critical patient-centered societal interest, and they should be revisited, they urge.

Dr. Peppercorn and coauthors have disclosed no relevant financial relationships.

J Clin Oncol. Published online January 24, 2011. Abstract

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