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Both/And, rather than Either/Or: Expert Panel Recommends Early Integration of Palliative Care into Treatment of Advanced Cancers

March 2nd, 2012 - by Dr. Jack West

http://blog.lungevity.org/2012/03/02/pc ... d-cancers/

The American Society of Clinical Oncology (ASCO) recently convened an expert panel that just published a “provisional clinical opinion” that advises oncologists to initiate a dedicated focus on palliative care right from the time that people with advanced or significantly symptomatic cancers are starting what we would consider “active treatment” for their cancer with things like chemo, targeted therapy, radiation, etc. This is likely to lead to some gradual changes in how palliative care is perceived by both patients and doctors, who have largely considered palliative care to be essentially synonymous with hospice care. Too often, because hospice services in the US have traditionally only been available for patients who are no longer receiving “aggressive” anticancer therapies with a goal of curing cancer or prolonging survival, palliative care and hospice have tended to be afterthoughts that get our attention only very briefly, often in a rushed period when someone with advanced cancer is declining rapidly. Patients in the US receive the benefits of hospice typically for an average of just a few days, despite the fact that these supportive interventions are meant to be available for many months for each patient with a terminal diagnosis. However, if palliative care and hospice are equated with “giving up”, and only available for people after their other treatments are completed, it creates a difficult challenge that deprives patients of the best symptom management and quality of life possible.

Instead, the idea is that palliative care, which is really a focus on open communication, symptom relief/optimal qualify of life, and good discussion of realistic goals of treatment is NOT mutually exclusive with life-prolonging anti-cancer therapy and may even be better than some more aggressive interventions. Palliative care in this framework is actually potentially thought of as its own specialty, with separate practitioners, rather than just something that oncologists offer if time allows and if they think of it. So the idea is that perhaps palliative care should be administered side by side with the treatments oncologists are providing, right from the beginning.

The panel starts the paper by explaining that the genesis of interest in the question of how and when to combine palliative care with conventional treatment strategies is predicated in large part on a clinical trial from Massachusetts General Hospital, a study of 151 patients recently diagnosed with advanced NSCLC who were randomized to standard treatment, generally focusing far more on aggressive treatment and then perhaps consideration of palliative care later, or an approach that initiates palliative care right from the beginning. Importantly, there was no clear schedule of how frequently patients were seen by a palliative care specialist or what was actually done. Despite the lack of uniform practice, patients randomized to palliative care along with “anti-cancer” therapy right from the beginning demonstrated many clinical improvements, ranging from better mood and less depression to lower hospitalization rates and medical costs. Most striking was the fact that these patients actually had a significant improvement in their overall survival, a difference 2.7 months (mo) (11.6 vs. 8.9 mo, P = 0.02). though the cause of this improvement isn’t clear, it may have been related to a significantly lower use of aggressive treatments such as chemotherapy toward the very end of life, better control of depression and other symptoms, or other unmeasured factors.

Nevertheless, this trial isn’t without its critics. Without any real uniform practices or details of the actual interventions pursued with palliative care in this trial, we are left with more or less of a “black box” that could make it hard to replicate these results elsewhere. This was also a group of only advanced NSCLC patients, predominantly Caucasian and treated in one tertiary care center. In addition, palliative care specialists aren’t readily available everywhere, particularly at the community-based clinics where more than 80% of adult cancer patients in the US receive their care. So it’s not clear that these findings could actually be expected to be generalizable outside of that particular center and clinical population.

Moreover, the results of the few other trials that have attempted to evaluate the value of palliative care interventions haven’t been as convincing in the extent of benefit. In the publication, the panel summarized the results from six reports that precededthe MGH paper: overall, these other studies are inconsistent in the differences and specifically the improvements conferred from proactive palliative care, other than lower costs associated with overall less utilization. Nevertheless, benefits in quality of life, mood, and participation in important decisions like end of life care was typically better, even if a survival benefit wasn’t seen elsewhere. There was certainly no evidence that any outcomes were worse with addition of palliative care.

The ASCO expert panel acknowledged the limitations in the rather scant research on palliative care, but in the end they were swayed by the positive results in the one MGH study and the fact that none of the studied demonstrated detrimental effects from early palliative care, with a wide range of favorable effects seen at least here and there across these trials. Taken together, the panel felt justified in offering a provisional clinical opinion that recognizes a need for far more research in this field while stating that referral to a palliative care specialist along with timely initiation of conventional care efforts for patients with metastatic or significantly symptomatic cancer is recommended.

Finally, it’s important to reflect that the MGH study that showed a surprising survival benefit from palliative care emerged in the context of a national debate about whether discussing end of life care and the goals of treatment are tantamount to “death panels” that will lead to shorter patient survival. Instead, this work suggested the opposite. I don’t know that we can necessarily expect patients to live significantly longer from palliative care (the improvement in survival is greater than the survival benefit of adding Avastin (bevacizumab) to standard chemo for advanced NSCLC, after all), but we can probably be reassured that living more comfortably doesn’t need to mean shortening survival.

The cancer care world will need to continue to work on how to actually implement these panel recommendations. There aren’t enough palliative care specialists, especially in far flung places; we also need to educate both doctors and patients to overcome the bias that palliative care is a consolation prize you get when you can’t improve survival. The distinction between anti-cancer therapy and palliative care isn’t an “either/or” situation. We should be able to both live better and live longer, rather than have these ideas be in competition with each other. This will be a gradual process, but I think that we’ll be heading in the right direction.

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