COMMENTARY

Nathan Cherny: ESMO Award a Nod to Integrated Palliative Care

David J. Kerr, CBE, MD, DSc, FRCP, FMedSci; Nathan I. Cherny, MD

Disclosures

October 12, 2015

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David J. Kerr, MD: Hi, I'm David Kerr, professor of cancer medicine at the University of Oxford. Welcome to this edition of Medscape Oncology Insights on palliative care, from the 2015 European Cancer Congress in Vienna. Joining us today is a great friend and colleague—almost a lifelong colleague through our work in the European Society for Medical Oncology (ESMO)—Professor Nathan Cherny. He is Norman Levan Chair for Humanistic Medicine at Shaare Zedek Medical Center in Jerusalem, and associate professor of medicine in Ben-Gurion University of the Negev in Beersheba, in Israel.

Welcome, Nathan. You've done a fantastic amount of work, which has been recognized, of course, by ESMO,[1] for promulgating palliative care. Tell us about that work.

Palliative Care Integrated into Cancer Management

Nathan I. Cherny, MD: It's not about promulgating palliative care. It's about integrating palliative care as part of the purview of good oncologic care.

Dr Kerr: When do we do that? Are we seeing palliative care as a sort of dust-bin at the end of so-called active treatment? Or should we be integrating earlier on into full and proper management?

Dr Cherny: What we know from patients is they are often some physically and psychologically symptomatic at a relatively early stage in the trajectory of the disease. For many patients, these issues are neglected until the very late stage of disease, and often the introduction of palliative care is almost as a hand-over—with a sense, then, of abandonment.

Dr Kerr: Of abandonment, loss, coming to the end of things. I couldn't agree more.

Dr Cherny: What we're advocating (and we've been advocating this now since 1999, since we've started the Palliative Care Working Group at ESMO) is that patients need a continuity of care in which care is integrated, between oncology and palliative care, from the time that needs arise—and that this ought to be a seamless association. That requires, to some degree, a change of medical culture.

Dr Kerr: Agreed.

Dr Cherny: At individual institutions, that requires infrastructural commitments and manpower commitments to make sure you have the people skilled to do these tasks, and that requires inculcating clinicians with an awareness that this is a part of their core activity.

Dr Kerr: Would you say that there are data supporting this model of care—that by integrating palliative care early in cancer management patients do better?

Dr Cherny: There are now compelling data. There are now two, possibly three, randomized studies[2,3,4] in which patients are randomly assigned to receive ad hoc palliative care or early institution of palliative care from the time that it's recognized that a patient has an advanced, incurable illness. Most of these studies were done on lung cancer. All of the studies showed that the quality of life of patients is substantially improved with early palliative care. In one of the earlier studies,[2] not only was the quality of life improved, but the duration of survival was also significantly improved.

I feel very confident saying that we can help people to live better and then ultimately, when it comes to a terminal phase, die with comfort. But there's also a possibility that the attention to detail, with meticulous and high-quality symptom control—that it may also affect the duration of survival. It is primarily important for the first reason; the other one may be an extra bonus we get out of it.

Training Oncologists in Palliative Care

Dr Kerr: You talked about cultural change. I'm old. I consider myself a generally well-trained physician. I think that I understand the use of morphine. I think I understand when I can detect a patient who is depressed or who is having other psychological problems, but don't you trust me with the palliative care of that patient?

Dr Cherny: I want oncologists to be skilled in palliative care. Not only do I want it, but ESMO wants oncologists to be skilled in palliative care. And in fact, as far back as 2003, ESMO laid out nine core elements of palliative care training,[5] which need to be part of oncologic training. I'll highlight some of these.

Oncologists need to be expert in the management of side effects of treatment, and they need to be expert in the management of pain, nausea, and vomiting. They need to be familiar with the management of psychological issues, such as depression, anxiety, and hopelessness; and they need to be familiar with the management of other common symptoms, such as shortness of breath, fatigue, nausea and vomiting, diarrhea, and constipation. These are the sorts of things that can plague our patients' lives and undermine the quality of life, not only for the patient but for the patient's family as well.

Dr Kerr: You've been enormously influential across Europe with the work that you and your colleagues on the Palliative Care Task Force have led in influencing the core curriculum for oncologists. You've also done some other brilliant work in parallel, by accrediting palliative care centers. Tell me about that.

Dr Cherny: By way of background, we studied the diffusion barriers—why was palliative care so difficult, why were oncologists so slow on the uptake?

Some of the barriers that we found that we could address were incentives. We wanted to create incentives. We wanted to increase the perceived value of being involved in palliative care. We also wanted to reduce its complexity, because palliative care is a complex task. By giving ESMO awards, that created an incentive. It also raised the profile of palliative care and said, "Hey, this is going to get us the attention of our peers."

As for the complexity, this was a challenge. In laying the criteria for accreditation, we went into quite substantial detail of what you need to be doing for each criterion, to be able to achieve it. This essentially was a roadmap for centers to say, "If I'm to be accredited, these are the things that I need to be doing." So it gave them...

Dr Kerr: Something to aim toward, to deliver the sort of services required.

Dr Cherny: Yes. So hospitals that started from nothing took the 13 criteria and said, "Okay, how can we build services around each of these?" Starting from scratch to getting accredited could be as short as 2 or 3 years.

Dr Kerr: Fantastic— sort of health service redesigned by the back door.

Dr Cherny: It's a checklist model.

ESMO Award Acknowledges Value of Integrated Palliative Care

Dr Kerr: You've been doing this for ages now. How many centers do you have under your umbrella?

Dr Cherny: We're now up to almost 200 centers. The exact number is 189 centers in 44 countries all over the world. This year we had new centers from Vietnam, Taiwan, Saudi Arabia, Kuwait, and the Sultanate of Oman, among others. We're affecting palliative care not just in Europe, but all over the world.

There's a fascinating story in Italy, where the first eight accredited centers formed a working group within the Italian oncologic society to promote the message, which they did effectively. We now have 35 centers in Italy alone.

Dr Kerr: It sounds like a religious cult, the way that you've built up. I'm teasing a little. But there's an awards ceremony tomorrow that you're involved in?

Dr Cherny: For this work and some of the other things I've been involved with, ESMO has awarded me, this year, the ESMO Award. For me, it's incredibly gratifying. It feels like they're signing on to the things I've ascribed as important for the delivery of quality cancer care in Europe. You know, initially we started out with a great degree of skepticism.

Dr Kerr: I remember.

Dr Cherny: Now everyone is convinced, not only that we're on the right path, but we've improved ESMO in promoting this.

Dr Kerr: Agreed.

Dr Cherny: And ESMO is now a world leader in this issue.

Dr Kerr: It's owing to you and to the many colleagues that you've worked with—it's been a team effort. But Nathan, thank you—a wonderful piece of work, beautifully described, and many, many congratulations on the ESMO Award.

Dr Cherny: Thank you very much.

Dr Kerr: So thanks for that. All of you, thanks for watching and listening, and this is David Kerr, reporting from the European Cancer Congress in Vienna, 2015. Thanks again.

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