Start Palliative Care at Diagnosis for Kids With Cancer

Fran Lowry

March 16, 2017

The time has come to begin palliative care for children as soon as they are diagnosed with cancer, say experts in the field.

"The findings of pervasive symptoms and suffering from the time of diagnosis make clear that pediatric oncologists cannot proceed as we have in the past," commented Jennifer W. Mack, MD, MPH, a pediatric oncologist at Dana-Farber/Boston Children's Cancer Center and Blood Disorders Center, in Massachusetts, in an interview Medscape Medical News.

Dr Mack was commenting on a study published online March 9 in JAMA Oncology. That study found that, far from being averse to the idea of palliative care, children with cancer and their parents had positive attitudes about it and would not be opposed to incorporating it early in the course of treatment.

"I see the results of this study as a call to action to pediatric oncologists to incorporate palliative care earlier on. All oncologists are being urged to do this, but maybe the pediatric oncos haven't done so yet and are now being urged to," said Dr Mack, who authored an accompanying editorial.

Dr Jennifer Mack

"The notion of palliative care for children with cancer is difficult to accept because it often delivers a message that the child will die, but the fact is, alleviation of symptoms and improved quality of life, regardless of outcome, is of paramount importance to kids and parents affected by cancer," said Dr Mack.

It is now recognized that early palliative care for cancer patients is optimal, yet significant barriers often prevent its implementation, write the study authors, led by Deena R. Levine, MD, St. Jude Children's Research Hospital, Memphis, Tennessee.

In the study, Dr Levine and her colleagues asked 129 children with cancer (68 boys, 61 girls) and their parents how they felt about early palliative treatment to relieve their symptoms and the side effects from cancer therapy.

Most of the children had experienced adverse effects from their treatment.

In the first month, 109 children (84.5%) reported nausea; 97 (75.2%) reported loss of appetite; 96 (74.4%) reported pain; 77 (59.7%) reported anxiety; 69 (53.5%) reported constipation; 64 (49.6%) reported depression; and 12 (23%) reported diarrhea.

The research showed that just two of the children (1.6%) and eight of the parents (6.2%) were opposed to meeting the palliative care team around the time of diagnosis.

In addition, very few patients and parents felt that early palliative care would interfere with their relationship with their oncologist.

Only six patients (4.7%) and five parents (3.9%) thought that early palliative care would interfere with the relationship with their oncologist, would interfere with their therapy, or would mean they had lost hope that they would be cured.

"This finding, that few in the study felt that introducing palliative care may undermine hope for a good outcome, is notable," Dr Mack said.

"It's especially hard for all of us ― clinicians, parents, children ― to think about a child dying and do anything other than everything we can do to help a child be cured. I just think the idea of providing palliative care to a child is a hard one emotionally. I think that is one of the barriers to pediatric palliative care. It's such an emotionally charged thing to be thinking about, but this study shows that parents and even the kids welcome the idea," she said.

"In fact, kids are very open to the idea, especially when it is framed as attention to symptoms and quality of life. That's a wonderful message, and as this study shows, it was very positively received," Dr Mack said.

Dr Mack said that in an ideal world, she would like to see dedicated care with attention to alleviation of symptoms and preservation of quality of life from the day of diagnosis.

"I think that the authors are right when they call for such care at diagnosis as being optimal for these children. As I mentioned in the editorial, we need to think about how that is delivered, because we do not have infinite resources. Some smaller centers in particular may be challenged to give palliative care to all kids," she said.

"But we need to think strategically about how to deliver the best care that provides the best attention to symptoms and quality of life from diagnosis and oncologists and palliative care physicians to work together to make sure that happens for every child," Dr Mack said.

The study was funded in part by the American Lebanese Associated Charities. Dr Levine and Dr Mack report no relevant financial relationships.

JAMA Oncol. Published Online March 9, 2017. Abstract, Editorial

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