Expanded Palliative Care for All Cancer Patients

Roxanne Nelson

February 07, 2012

February 7, 2012 ( UPDATED March 1, 2012 ) — A provisional clinical opinion from the American Society of Clinical Oncology (ASCO) extends early palliative care to all patients with metastatic cancer, although the evidence so far shows a survival benefit only in patients with metastatic nonsmall-cell lung cancer (NSCLC).

The new advice, published online February 6 in the Journal of Clinical Oncology, recommends that palliative care should be offered to patients with metastatic NSCLC at the time of initial diagnosis, alongside concurrent standard cancer therapy. This is based on strong evidence from a phase 3 clinical trial that demonstrated a survival benefit from integrating palliative care into cancer therapy early in the course of care (N Engl J Med. 2010;363:733-742).

The panel notes that even though a "survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings, substantial evidence demonstrates that palliative care — when combined with standard cancer care or as the main focus of care — leads to better patient and caregiver outcomes."

"Therefore, it is the panel's expert consensus that combined standard oncology care and palliative care should be considered early on in the course of illness for any patient with metastatic cancer and/or a high symptom burden."

Incorporating palliative care earlier on improves patients' symptoms, quality of life, and satisfaction, and reduces the burden on caregivers, the panel notes. It also leads to more appropriate referral to and use of hospice, and decreases the use of futile intensive care.

"Palliative care is about maintaining quality of life throughout the cancer journey," said Jamie Von Roenn, MD, coauthor of the 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.

In advanced cancer, "the data are increasingly showing us that palliative care can be incredibly valuable for patients and their caregivers from the time they are diagnosed, not just at the end of life," she said in a statement.

Improves Survival, Quality of Life

The optimal delivery of palliative care needed to improve patient outcomes has not yet been clarified; the evidence continues to evolve. However, according to the expert panel, no trials to date have demonstrated any harm to patients or caregivers or excessive costs associated with this regimen.

Nearly half of all patients with metastatic cancer cannot be cured with currently available treatments, but they can survive for years after diagnosis. The focus of palliative management emphasizes medically appropriate goal setting, honest and open communication with patients and families, and meticulous symptom assessment and control, the panel writes.

Unfortunately, the current medical-care model in the United States is unable to meet the needs of many patients dealing with advanced illness. Both the quality and associated costs of healthcare, particularly for those with advanced disease, have become central in the healthcare reform debate.

The expert panel points out that 7 randomized controlled trials have shown that concurrent palliative care in patients with advanced cancer maintains or improves survival and quality of life. In addition, most studies demonstrate that these improved outcomes are achieved at a lower cost than standard oncologic care alone.

"Preserving quality of life is of utmost importance for all patients," said coauthor Tom Smith, MD, professor of oncology and director of palliative care at Johns Hopkins Medicine in Baltimore, Maryland. "We now have strong evidence in metastatic cancer that combining palliative care with standard cancer treatment improves our 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," said Dr. Smith in a release.

More Studies Needed

Strategies to optimize concurrent palliative and standard oncology care and to evaluate its impact on patient and caregiver outcomes and on society should be an area of intense research, the authors conclude.

Areas that need to be evaluated in future studies include the optimal timing and venue for palliative care, such as inpatient and outpatient/community settings; evidence-based reimbursement models to support the use of palliative care; the components of palliative care that are effective; such a regimen in diseases other than advanced lung cancer; and the way palliative care affects the continuum of care, particularly during the delivery of antitumor therapy.

The authors have disclosed no relevant financial relationships.

J Clin Oncol. Published online February 6, 2012. Abstract

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