Novel Tool Identifies Palliative Care Needs Early in Cancer

Liam Davenport

September 09, 2017

MADRID, Spain — A novel tool to proactively refer patients with lung cancer to palliative care early after diagnosis can identify palliative care needs even in patients with a good functional status, say researchers from a leading cancer center in the United Kingdom. They also found that the tool could be successfully integrated into existing oncological services.

The findings were presented here at the European Society for Medical Oncology (ESMO) 2017 Congress by Jayne Wood, MD, Symptom Control and Palliative Medicine, Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom.

She noted that the Royal Marsden Hospital is an ESMO Designated Centre of Integrated Oncology and Palliative Care in recognition of its high standard of integration for the two disciplines.

The novel tool, known as Triggers, was developed by the London Cancer Alliance to help clinicians assess their patients' palliative care needs at a much earlier stage than is traditionally the case, and potentially refer them for palliative care alongside active treatment.

The tool was tested in the hospital's lung cancer outpatient clinic during a 4-month period, and the results from this initial study showed that more than four fifths of new patients with lung cancer underwent assessment for palliative care within 2 months of their first visit. Of these patients, three quarters had palliative case needs, despite having a good functional status.

"This tells us that we are addressing a real need, and that the tool is picking up a group of patients who have a real potential to benefit from referral to specialist palliative care," Dr Wood commented in a statement.

"The goal is for the tool to become standard and easy for anyone on a patient's primary care team to use," she added. "For us, the next step will be to expand into other tumour groups."

Reacting to the findings, Matti S. Aapro, MD, dean of the Multidisciplinary Oncology Institute in Genolier, Switzerland, and chair of the Supportive/Palliative Care Track at the ESMO 2017 Congress, said: "It is a pleasure to read about these observations."

"The concepts of supportive and palliative care are about a continuum in patient care, and need to be given more importance, even in these days of exciting results about new therapies."

Study Details

Although there is evidence that offering palliative care early on in cancer can be beneficial to patients, and guidelines now recommend such an approach, referrals to such services tend to occur later and are centered on end-of-life care, the researchers note.

They set out to normalize the provision of palliative care alongside the delivery of active treatment in the study they designed, in which the rate and degree of review of all new patients attending an outpatient lung oncology clinic by the integrated palliative care service was assessed.

Specifically, they evaluated the implementation of the Triggers tool to aid the integration of oncological and palliative care, in which patients were classified as "trigger positive" or "trigger negative" on the basis of their overall need for care.

The palliative care needs of all trigger-positive patients were then assessed in detail, using the Integrated Palliative Outcome Scale.

In addition, the patients' Eastern Cooperative Oncology Group Performance Status, among other measures, were also determined, and they were followed-up longitudinally.

Presenting data from the first 4 months of the service, the team reports that 115 new patients attended the outpatient clinic, of whom 97 (84%) were reviewed by the integrated palliative care service within 2 months of their first appointment at the clinic.

It was found that 73 (75%) of the reviewed patients had at least one positive score on the trigger tool items, indicating some form of palliative care need, with 70 classified as trigger positive. Moderate palliative care needs on at least one Integrated Palliative Outcome Scale item were identified for 68 patients, whereas 57 had severe or overwhelming palliative care needs.

Importantly, the researchers note that 57 of the 70 trigger-positive patients had an Eastern Cooperative Oncology Group Performance Status of 0 to 1.

They say their integrated palliative care service "is feasible and identifies patients with palliative care needs who would benefit from early palliative care referral."

The team emphasizes that they will continuing evaluating the service for 12 months, "which will facilitate analysis of other patient outcomes (eg, time between PC referral and death)."

May Reduce Overall Costs

Discussing the study after its presentation, Andreas Charalambous, PhD, assistant professor (acting) of Oncology and Palliative Care, Cyprus University of Technology, Limassol, said an "early focus on care aims at improved quality of life."

He added: "It has been shown that it can improve patient satisfaction, reduce depression and anxiety, and lead to care more consistent with patient preferences. In addition, such care may improve survival and reduce overall costs."

However, Dr Charalambous noted, "despite all the benefits that are piling up in the literature, we do see that, at the moment, in terms of the integrated model of care, we don't have a global golden standard of when and how to do this, and this is sad."

We don't have a global golden standard of when and how to do this, and this is sad. Dr Andreas Charalambous

For him, the Triggers integrated palliative care service therefore "provides an effective model" to address some of the issues in delivering such care, "and at the same time, this model reveals the pivotal role of placing the patient at the center of multidisciplinary and multidisciplinary care."

From the podium, Dr Charalambous asked Dr Wood what challenges they faced in implementing the model.

Dr Wood replied that they had to respond to feedback from the oncologists on how to incorporate palliative care on a logistical level, in terms of room space and how it would fit in with the clinic, but in a way that was "appropriate alongside the conversations that are happening for all who were newly diagnosed with lung cancer."

Dr Wood continued: "So the big challenge was finding a model that would be appropriate and sensitive for patients coming into the Royal Marsden, often as their first appointment."

She noted that another challenge was one of sustainability, in terms of being able to offer the model during the longer term, and the third "was making sure that the referrals that we make are appropriate, and could be managed by the resources that are available in the communities."

This, Dr Wood said, "involved really close collaboration with the key stakeholders across oncologists, patients, and the community professionals."

The authors and commentators have disclosed no relevant financial relationships.

European Society for Medical Oncology (ESMO) 2017 Congress: Abstract LBA54_PR. Presented September 8, 2017.

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