Nearly half of all patients with metastatic cancer have incurable disease, but these individuals can live for years after their initial diagnosis. This is a period in which palliative care can be used to improve quality of life (QOL) for patients and caregivers.

Studies indicate that many patients are not referred to specialized palliative care services or to hospice until they’re near the end of life. Delaying palliative care reduces opportunities for clinicians to address physical symptoms and the emotional, social, and spiritual needs of patients and caregivers.

Potential Benefits

In 2012, the American Society of Clinical Oncology (ASCO) issued a provisional clinical opinion (PCO) on integrating palliative care into standard oncology care. The document was prompted by seven randomized controlled trials showing that providing palliative care together with standard oncologic care in patients with advanced cancer can be beneficial. Potential benefits of earlier palliative care involvement include:

– Improvement in symptoms, QOL, and patient satisfaction.
– Reduced caregiver burden.
– More appropriate referral to and use of hospice.
– Decreased use of futile intensive care.

Furthermore, most of these studies demonstrated improved outcomes at a cost lower than that of standard oncologic care alone. No trials to date have demonstrated harm to patients and caregivers or excessive costs from early involvement of palliative care. As such, palliative care should be considered earlier in the course of illness for any patient with metastatic cancer or high symptom burden.

Palliative-Metastatic-Cancer-Callout

Hurdles Ahead

Despite growing evidence supporting the use of palliative care concurrent with standard oncologic care, health policy and reimbursement mechanisms to facilitate its implementation early in the disease course are not widely available. Inpatient consultative palliative care services are becoming more prevalent, but clinic-based and community-based non-hospice palliative care services are only now becoming more readily available. Palliative care physicians and multidisciplinary providers will be required to meet the anticipated growing demand. Greater emphasis is needed to align health policy and reimbursement so that palliative care use can be optimized.

Future Research

Strategies to optimize concurrent palliative and standard oncology care should be an area of intense research. Studies are needed to evaluate the optimal timing and venue for provision of palliative care. More research into evidence-based reimbursement models that support palliative care provision is also warranted. Another area of research that would be beneficial includes determining which components of palliative care have the greatest impact across the continuum of care. This PCO is only a beginning step in ASCO’s ongoing efforts to ensure that patients with advanced cancer have access to high-quality palliative care. These efforts, however, are critical to addressing the complex needs of patients and their caregivers.

References

Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol. 2012;30:880-887. Available at: http://jco.ascopubs.org/content/30/8/880.full.pdf+html.

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;363:733-742.

Von Roenn JH, Temel J. The integration of palliative care and oncology: the evidence. Oncology (Williston Park). 2011;25:1258-1260, 1262, 1264-1265.

Brumley R, Enguidanos S, Jamison P, et al: Increased satisfaction with care and lower costs: Results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55:993-1000.

Gade G, Venohr I, Conner D, et al: Impact of an inpatient palliative care team: A randomized control trial. J Palliat Med. 2008;11:180-190.