The impact of early palliative care: a medical oncologist’s perspective
Review Article on Clinical Challenges and Pitfalls in Early Palliative Care: Practical Knowledge and Guidance from other Medical Specialties

The impact of early palliative care: a medical oncologist’s perspective

William Raskin

Department of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

Correspondence to: William Raskin. Department of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. Email: williamr.raskin@sunnybrook.ca.

Abstract: The role of early palliative care involvement for patients with cancer is being increasingly recognized for patients with incurable cancer as more studies demonstrate that it is feasible, cost-effective and efficacious. Patients benefit from improved symptom control, better supported decision making and improved quality of life. It has been shown to be effective alongside disease-modifying treatment, and evidence supports the use of multidisciplinary care in a co-management role. It is also a cost-effective way to reduce unnecessary and overly-aggressive treatment at the end of life. Efforts are needed to alleviate persistent misconceptions and support program development in areas where access is limited.

Keywords: Palliative care; supportive care; symptom management


Submitted Mar 12, 2019. Accepted for publication Jun 13, 2019.

doi: 10.21037/apm.2019.10.02


The field of oncology has grown increasingly complex in the last two decades with patients being offered a broad array of treatment options and surviving longer (1). Given these trends, there is increased need to support patients’ physical, psychological and existential needs and relieve suffering. The role of early palliative care involvement for patients with cancer is being increasingly recognized. For patients with incurable cancer, it is demonstrated to be a feasible, cost-effective and efficacious way to improve quality of life and may impact overall survival (2,3). Reflecting this growing emphasis are recent guidelines and metrics that include early palliative care involvement as a marker of high quality care (4,5).

The WHO defines palliative care as a holistic approach to care of patients and their families facing life-threatening illness and recognizes its role early in the course of disease concurrently with disease-modifying treatment (6). The practice focuses on patient wellbeing and the scope of practice is extremely broad. In addition to providing symptom-directed care, ASCO recognizes multiple other components in the palliative care of cancer patients, including rapport-building, addressing illness understanding and prognosis, assessing coping and support mechanisms, and aiding in treatment decision making. Within this broad scope of practice usually operates a multidisciplinary team, including physicians, nursing, social work and spiritual care. The most validated successful models include a consultation service available in both the inpatient and outpatient setting (7). Different outpatient care models, exist, ranging from stand-alone clinics to fully integrated multidisciplinary clinics. This multidisciplinary model aims to facilitate communication between specialists, lessen the burden of patient visits and allow for earlier management of disease or treatment related symptoms.

Dedicated palliative care services and multidisciplinary clinics are resource-dependent; many hospitals do not have access to dedicated palliative care services in community settings (8). Yet, even in resource-rich settings, misconceptions persist that limit access. Many oncologists at comprehensive cancer centres still only involve palliative care services for patients with uncontrolled symptoms or when patients are close to the end of life (9). Furthermore, negative emotions predominate patient perceptions of palliative medicine, leading to fear and avoidance (10).

One rationale for the benefit of early involvement of palliative is the high burden of suffering that cancer patients experience. Although the frequency and burden of physical symptoms varies between different disease sites, cancer patients report a high prevalence of symptoms of distress that impact their quality of life, including fatigue, nausea, pain, weakness, lack of appetite, and drowsiness (11). Additionally, a cancer diagnosis is associated with risk of psychological morbidity, with high incidence of anxiety and depression for patients and family members alike (12). A patient’s initial visit with their oncologist is appropriately focused on establishing a correct diagnosis and treatment plan. Yet, in an environment with aging demographics, increasing cancer incidence, and increased patient complexity, the oncologist may be unable to optimally assume all aspects of patient care. The involvement of palliative medicine alongside the oncologist provides different but complimentary approaches to care and more opportunity to address suffering in an at-risk population. The benefits are clear; early palliative care involvement in patients with incurable cancer has consistently shown improvements in patient quality of life and symptom burden (3,13). In addition, one study of patients with early-stage lung cancer described a similar benefit at 12 weeks, suggesting this benefit extends to patients being treated with curative intent (14). This is unsurprising, given the substantial morbidity and treatment-related toxicity that patients experience at diagnosis, during and after active treatment.

In addition to improving quality of life and symptom control, the involvement of palliative medicine may even impact overall survival for cancer patients. While not all studies have shown such a benefit, one randomized trial of early palliative care referral for patients with metastatic non-small cell lung cancer demonstrated a 2.7-month survival benefit (2). The explanation for this outcome is unclear, but it is hypothesized that improved mood and better symptom control, establishing better support networks, and facilitating better treatment decision-making may have contributed to the effect. Interestingly, a recent trial of web-based symptom reporting system showed a 5.2-month overall survival benefit compared to the standard care and follow up, highlighting the impact of promptly recognizing symptoms of distress (15). The integration of palliative medicine to cancer care improves recognition and intervention to patient-reported outcomes.

A further and important role of the palliative care team is improving illness understanding and treatment decision-making. In order to empower patients to make treatment decision, a realistic disclosure of expectations, prognosis and goals of treatment is essential. Studies have suggested that patients want to be informed of their prognosis, but often have poor understanding of their illness and goals of treatment (16,17). This disconnect is reflected by oncologists having a tendency to be overly optimistic in their survival estimates, and often only provide this information if it is requested (18). More so, oncologists do not often engage in discussions around end of life care. and documentation of advance directives and goals of care discussion is sparse (19,20). Without these discussions, patients are at risk of receiving unwanted treatment at the end of life (21). Having a trusting, longitudinal relationship can alleviate some of the barriers associated with these difficult conversations. Palliative care providers can reinforce an oncologist assessment of prognosis and take time to explore patients’ wishes and goals that help guide treatment decisions.

As the cancer treatment increasingly involves multiple agents and costly treatments, palliative care involvement may be cost effective. Cancer patients often receive chemotherapy within short weeks of the end of life and end up admitted to acute care and intensive care units (22,23). These interventions are not only costly, but associated with poor quality of life, worse caregiver satisfaction, delayed referral to hospice and lack of meaningful gains in survival (24,25). Early palliative care has been shown to reduce chemotherapy use at the end of life and facilitate advance care planning (26). Through cost-avoidance, palliative care services may reduce hospital costs without compromising quality of care (27,28). This cost-effective intervention has impact in resource-constrained settings as well; where standard disease modifying treatments may be unavailable, palliative care services through a multidisciplinary team or primary care has been recognized as a cost-effective way to improve quality of life for patients with cancer (29).

In summary, there is growing recognition that early palliative care is a valuable component in the care of patients with cancer. It has shown to be efficacious, feasible and cost effective in improving patients’ quality of life. Further efforts are warranted to mitigate misconceptions and improve access.


Acknowledgments

Funding: None.


Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Jan Gaertner, Charles B. Simone II and Fiona Lim) for the series “Clinical Challenges and Pitfalls in Early Palliative Care: Practical Knowledge and Guidance from other Medical Specialties” published in Annals of Palliative Medicine. The article was sent for external peer review organized by the Guest Editors and the editorial office.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/apm.2019.10.02). The series “Clinical Challenges and Pitfalls in Early Palliative Care: Practical Knowledge and Guidance from other Medical Specialties” was commissioned by the editorial office without any funding or sponsorship. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.


References

  1. Cancer Statistics. NCI 2018. Available online: https://www.cancer.gov/about-cancer/understanding/statistics
  2. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-42. [Crossref] [PubMed]
  3. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: The Project ENABLE II randomized controlled trial. JAMA 2009;302:741-9. [Crossref] [PubMed]
  4. Ferrell BR, Temel JS, Temin S, et al. Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2017;35:96-112. [Crossref] [PubMed]
  5. American Society of Clinical Oncology Quality Oncology Practice Initiative: 2014 Quality Clinical Data Registry Measures.
  6. WHO definitions: palliative care. Available online: https://www.who.int/cancer/palliative/definition/en/
  7. Greer JA, Jackson VA, Meier DE, et al. Early Integration of Palliative Care Services With Standard Oncology Care for Patients with Advanced Cancer. CA Cancer J Clin 2013;63:349-63. [Crossref] [PubMed]
  8. Goldsmith B, Dietrich J, Du Q, et al. Variability in access to hospital palliative care in the United States. J Palliat Med 2008;11:1094-102. [Crossref] [PubMed]
  9. Wentlandt K, Kryzanowska M, Swami N, et al. Referral Practices of Oncologists to Specialized Palliative Care. J Clin Oncol 2012;30:4380-6. [Crossref] [PubMed]
  10. Zimmermann C, Swami N, Kryzanowska M. Perceptions of palliative care among patients with advanced cancer and their caregivers. CMAJ 2016;188:E217-27. [Crossref] [PubMed]
  11. Cheung WY, Barmala N, Zarinehbaf S, et al. The Association of Physical and Psychological Symptom Burden with Time to Death Among Palliative Cancer Outpatients. J Pain Symptom Manage 2009;37:297-304. [Crossref] [PubMed]
  12. Cheung WY, Le LW, Zimmerman C. Symptom clusters in patients with advanced cancers. Support Care Cancer 2009;17:1223-30. [Crossref] [PubMed]
  13. Zimmermann C, Swami N, Krzyzanowska M. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014;383:1721-30. [Crossref] [PubMed]
  14. Ferrell B, Sun V, Hurria A, et al. Interdisciplinary Palliative Care for Patients with Lung Cancer. J Pain Symptom Manage 2015;50:758-67. [Crossref] [PubMed]
  15. Basch E, Deal AM, Dueck AC, et al. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. JAMA 2017;318:197-8. [Crossref] [PubMed]
  16. Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med 2012;367:1616-25. [Crossref] [PubMed]
  17. Pronzato P, Bertelli G, Losardo P, et al. What do advanced cancer patients know of their disease? A report from Italy. Support Care Cancer 1994;2:242-4. [Crossref] [PubMed]
  18. Lamont EB, Christakis NA. Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med 2001;134:1096-105. [Crossref] [PubMed]
  19. Heyland DK, Barwich D, Pichora D, et al. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med 2013;173:778-87. [Crossref] [PubMed]
  20. Horton J, Hwang M, Ma J, et al. A single-center, retrospective chart review evaluating outpatient code status documentation in the EPIC electronic medical record for patients with advanced solid tumor cancer. J Clin Oncol 2013;31:242. [Crossref]
  21. Mack JW, Cronin A, Keating NL, et al. Associations between end-of-life discussion characteristics and care received near death: a prospective cohort study. J Clin Oncol 2012;30:4387-95. [Crossref] [PubMed]
  22. Temel JS, McCannon J, Greer JA, et al. Aggressiveness of care in a prospective cohort of patients with advanced NSCLC. Cancer 2008;113:826-33. [Crossref] [PubMed]
  23. Earle CC, Neville BA, Landrum MB, et al. Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 2004;22:315-21. [Crossref] [PubMed]
  24. Saito AM, Landrum MB, Neville BA, et al. The effect on survival of continuing chemotherapy to near death. BMC Palliat Care 2011;10:14. [Crossref] [PubMed]
  25. Christakis NA, Iwashyna TJ. The health impact of health care on families: a matched cohort study of hospice use by decedents and mortality outcomes in surviving, widowed spouses. Soc Sci Med 2003;57:465-75. [Crossref] [PubMed]
  26. Greer JA, Pirl WF, Jackson VA, et al. Effect of Early Palliative Care on Chemotherapy Use and End-of-Life Care in Patients With Metastatic Non-Small-Cell Lung Cancer. J Clin Oncol 2012;30:394-400. [Crossref] [PubMed]
  27. Smith S, Brick A, O’Hara S, et al. Evidence on the cost and cost-effectiveness of palliative care: A literature review. Palliative Medicine 2014;28:130-50. [Crossref] [PubMed]
  28. May P, Garrido MM, Cassel JB, et al. Prospective Cohort Study of Hospital Palliative Care Teams for Inpatients With Advanced Cancer: Earlier Consultation Is Associated With Larger Cost-Saving Effect. J Clin Oncol 2015;33:2745-52. [Crossref] [PubMed]
  29. Osman H, Shrestha S, Temin S, et al. Palliative Care in the Global Setting: ASCO Resource-Stratified Practice Guideline. J Glob Oncol 2018;4:1-24. [PubMed]
Cite this article as: Raskin W. The impact of early palliative care: a medical oncologist’s perspective. Ann Palliat Med 2020;9(3):1292-1295. doi: 10.21037/apm.2019.10.02