Updated ASCO Guidelines Stress Early Start to Palliative Care

Fran Lowry

November 16, 2016

The time to start palliative care is as soon as a patient's cancer becomes advanced, emphasize the authors of the American Society of Clinical Oncology (ASCO) Clinical Practice Guideline Update.

The Update was published online October 31 as a Special Article in the Journal of Clinical Oncology.

Jennifer S. Temel, MD, Harvard Medical School and Massachusetts General Hospital Cancer Center, Boston, one of the authors of the updated guidelines, told Medscape Medical News that the decision to add recommendations was based on several new, well-conducted randomized trials that consistently showed benefits of palliative care, especially if started early.

Dr Jennifer S. Temel

"The previous guidelines came out in 2012," she noted. "In the 3 years since then, there have been a number of new, well-conducted randomized trials that showed continued benefits of palliative care, and ASCO felt that it was important to update the evidence base and make the recommendations for early palliative care even stronger," Dr Temel said.

"We are excited that these guidelines are coming out and making an even stronger recommendation for focusing on palliative care for patients with advanced cancer. It's a very exciting development," she said.

Experts from the ASCO Ad Hoc Palliative Care Expert Panel developed the current update, which was based on a systematic review of all randomized clinical trials, systematic reviews, and meta-analyses, as well as secondary analyses of randomized controlled trials published from March 2010 to January 2016.

"As we reviewed all of these data, it became clear that palliative care should be initiated early in the disease course in patients with advanced cancer, along with active treatment, so that is one new recommendation since 2012," Dr Temel said.

The second update recognizes the important role that nurses, nurse practitioners, and other healthcare professionals play in providing palliative care.

Palliative care should be provided by interdisciplinary teams. Dr Jennifer S. Temel

"This specific recommendation was not included in the initial guidelines. It's that palliative care should be provided by interdisciplinary teams. Many of the studies that we reviewed involved nurses or nurse practitioners in palliative care so the update now recognizes that these health professionals can provide palliative care," she said.

"Palliative care is very commonly not provided exclusively by physicians and so it's a multidisciplinary team approach. This version of the guidelines now makes that clear — that multidisciplinary clinicians should play a role in palliative care," Dr Temel said.

Also new in the update is the observation that palliative care is also very helpful to the families and caregivers of patients.

"We have new studies that show that when patients are getting palliative care, the outcomes are better for their caregivers. This was an area that was not included in the initial guidelines, so the observation that palliative care also helps the families or loved ones is based on new data. It's not so much a recommendation, but rather a recognition that palliative care benefits not only patients but the caregivers themselves," she said.

The update also highlights disparities among different racial and ethnic groups in the delivery of palliative care.

"We know that there are a lot of disparities in the delivery of end-of-life care for different racial and ethnic groups, and even geographically with rural populations. The guidelines address that and suggest that we make sure we are providing expert palliative care and end-of-life care to patients across different racial ethnic groups and geographic locations," Dr Temel said.

Financially Advantageous to Hospitals

"These guidelines propose earlier outpatient access for cancer patients," Eduardo Bruera, MD, professor, The University of Texas MD Anderson Cancer Center, Houston, commented to Medscape Medical News. He was not involved in drawing up the new recommendations.

"Outpatient centers are needed in all cancer centers. At MD Anderson we have operated one for the last 17 years, but it continues to be the only one in Houston," Dr Bruera added.

"Early palliative care is very important for the whole-person care of the patient and family, and there is strong evidence that it is financially advantageous for hospitals. These guidelines hopefully will inspire universal access to palliative care for cancer patients," he said.

Dr Temel and Dr Bruera have disclosed no relevant financial relationships.

J Clin Oncol. Published online October 31, 2016. Full text

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