Oncology and Palliative Medicine: Providing Comprehensive Care for Patients With Cancer

INTRODUCTION

Oncologists are tasked with the care of complex patients in a rapidly evolving field of new therapies through which patient survival has been prolonged. These changes to the cancer trajectory have augmented patients' need for symptom control and supportive care because patient and caregiver distress may be challenging and prolonged. In the evolving field of oncology, palliative medicine has a growing and important role in managing sources of patient distress and improving patient quality of life (QOL). In this review, we discuss the role of palliative medicine in the practice of oncology, the delivery of palliative medicine and barriers to delivery, the cost effectiveness of palliative medicine, and national guidelines and society recommendations for integrating palliative medicine in oncology.

THE ROLE OF PALLIATIVE MEDICINE

Palliative medicine is the specialized care of people living with serious illness that focuses on alleviating the burden of symptoms and improving QOL.1 Palliative medicine is appropriate for patients of any age and at any stage of serious illness. It is ideally provided concurrently with curative and life-prolonging treatments. Palliative medicine teams work alongside a patient's team of specialists to provide symptom and communication expertise, emotional support, assistance with medical decision making, and assistance with end-of-life care and bereavement support when appropriate.

Oncologists and primary care physicians provide primary palliative care for initial symptom control, including management of pain and non–pain symptoms of the cancer diagnosis, cancer treatment including stem cell transplants, and cancer survivorship. The approach to primary symptom therapy involves the entire oncology care team with the involvement of additional specialty services such as psychiatry, radiation oncology, and surgery as needed. Secondary palliative care is provided by teams of palliative medicine specialists who build upon the care already provided during primary palliative services.2,3 Core palliative medicine teams generally consist of physicians, nurses, social workers, and chaplains. Other providers such as psychologists, pharmacists, child life specialists, and music and art therapists are often a part of the multidisciplinary palliative medicine team. Secondary palliative care can facilitate the treatment of challenging symptoms of cancer, including refractory or atypical pain, cancer fatigue, and anorexia. The addition of secondary palliative care enhances the multidisciplinary team and addresses the patient's needs beyond symptom management: psychosocial needs, caregiver stewardship, and advance care planning. Hannon et al reported in a qualitative study that patients discern distinct roles between their oncologist who provides cancer therapy and their palliative medicine providers who provide symptom control and emotional support.4 A study by Dow et al also showed that patients with cancer may prefer to discuss end-of-life issues with a physician other than their oncologist.5

Evidence shows that early introduction to palliative medicine improves QOL for patients with cancer. In the landmark study by Temel et al, patients with metastatic non–small cell lung cancer were randomized into 2 groups: standard oncology care vs standard oncology care with the integration of outpatient palliative medicine consultation and follow-up visits.6 The group randomized to palliative medicine had improved QOL, anxiety screening, and depression screening scores. Additionally, patients in the palliative medicine group had a lower percentage of deaths in the hospital, less aggressive end-of-life care, and higher rates of resuscitation status preference documentation. Interestingly, improved median survival was also noted in the group receiving palliative care (11.6 vs 8.9 months).6 A metaanalysis of randomized controlled trials in palliative care also showed an association between palliative care intervention and improved patient QOL and decreased symptom burden.7 Caregiver outcomes were variable but consistently showed improvement in caregiver satisfaction.

Patient and family support is essential to the field of palliative medicine. Patients and families often have higher rates of satisfaction with their medical care and the quality of communication and support when palliative medicine teams are involved.8 Palliative medicine teams also help patients and families as they transition to end of life and often assist with bereavement support. Early palliative medicine involvement can help families feel less angry and less in denial about the anticipated death of their loved one.9

DELIVERY OF PALLIATIVE MEDICINE

Palliative medicine can be provided in a variety of settings, including inpatient hospital consultation, dedicated palliative medicine units, hospital units, outpatient clinics, assisted living and long-term care facilities, and even home-based care. The most familiar model of palliative medicine delivery is inpatient-based services that may involve a single practitioner, consultant palliative medicine team, or even a palliative medicine hospital unit.10 Inpatient palliative medicine should be available for specialty consultation throughout the entire hospital setting—from the emergency department to the intensive care unit.

Outpatient oncology access to palliative medicine is a priority as the majority of oncology care is ambulatory. However, fewer than half of the nation's palliative medicine programs have outpatient services because of challenges in implementation, largely attributable to a palliative medicine workforce shortage.11,12 Early access to outpatient palliative medicine facilitates longitudinal care throughout the patient's cancer trajectory and improves the transition of care through the spectrum of healthcare settings.13 A single visit with a palliative medicine provider will not fully address the needs of any patient. Establishing palliative medicine clinics in ambulatory oncology practices provides the advantages of increasing access to higher volumes of patients in need, facilitating early referral, and improving communication between the oncologist and palliative medicine team.14

Project ENABLE (Educate, Nurture, Advise, Before Life Ends) showed that palliative medicine can be successfully implemented in a variety of oncology practice models, including cancer centers, private practices, and rural clinics using advanced practice practitioners and via a variety of patient encounters including individual and group meetings. Project ENABLE also showed that palliative medicine can be implemented at the time of advanced cancer diagnosis and that the telephone is a feasible method of intervention.15 The randomized controlled trial ENABLE II further tested the telephone model of intervention and reported an improvement in patient QOL.16 Patients had a lower risk of death in the year after trial enrollment (hazard ratio 0.67, 95% confidence interval 0.496-0.906, P=0.009) and had increased median survival compared to controls at 14 vs 8.5 months (P=0.14). When a similar intervention was provided for caregivers of patients with advanced cancer in ENABLE III, caregivers in the intervention group had significantly lower depression scores and stress burden, further supporting early palliative medicine consultations in oncology.17

BARRIERS TO PALLIATIVE MEDICINE DELIVERY

One barrier to palliative medicine referrals is the common misperception that palliative care is only associated with end of life.18 However, patients accept palliative medicine intervention without a loss of hope; the ENABLE and ENABLE II studies showed decreased depression in patients who received palliative care, providing evidence that palliative medicine consultations should not be postponed until failure of therapy, symptom crises, or end of life.15,16 One simple yet apparently effective measure for divesting the stigma of palliative care as end-of-life care rather than an additional form of cancer therapy is to add the term supportive care to the name of the palliative medicine team.19 Identifying palliative medicine teams as Palliative Medicine and Supportive Care helps bridge some of the barriers oncologists have in referring patients to palliative medicine services.20-24

The National Comprehensive Cancer Network criteria for patient consultation with palliative medicine include poor pain control, multiple allergies to pain medications, refractory non–pain symptoms, severe comorbidities, and inability to fulfill advance care planning.25 Referrals in practice are usually physician initiated, creating significant variability in patterns of palliative medicine involvement despite the availability of referral guidelines. Clinical symptom and distress screening to trigger palliative medicine consultations by predefined criteria has the potential to improve early referrals.26-28 Automated referral based on patient symptoms or distress screening scores has been studied in randomized clinical trials and is recommended.6,16,29,30 However, automated referrals are not feasible in most oncology practices because of the palliative medicine workforce deficit. Institutions and private practices need to develop practical pathways for automated referral to secondary palliative care in addition to enhancing the quality of primary palliative care services available.

COST EFFECTIVENESS OF PALLIATIVE MEDICINE

Healthcare costs and utilization for patients with cancer, especially advanced cancer, and end-of-life care are significant. A study published in 2013 reported a median survival of 3.4-4.7 months for patients with cancer after an unexpected hospital admission, with 73.5%-74.8% of patients deceased by 1 year.31 A study by Adelson et al showed that 30-day readmission rates decrease significantly after standardized palliative medicine consultations.28 Other studies report that direct hospital costs decreased by 14%-32% when palliative medicine consultation was provided within 2 days of admission.32,33 Palliative care consults provided within 1-10 days of admission provide a significant cost savings.33-35 Consults provided within 6 days of admission provided a significant direct cost savings of approximately 14%.33 Another study suggests that patients on Medicaid who receive an early palliative medicine consultation are more likely to receive care outside of the intensive care unit, are less likely to be hospitalized repeatedly, and enroll in hospice earlier.36 Referral to outpatient palliative care within 3 months of the end of life also decreases hospital admission, decreases costs, increases hospice utilization, and improves patient QOL.37,38 The Centers for Medicare and Medicaid Services provides separate payment for advance care planning discussions, a benefit that should promote palliative medicine services.39 Appropriate use of palliative medicine services can yield institutional annual savings of nearly $2 million by decreasing patient length of stay and daily hospital costs.40,41

SOCIETY RECOMMENDATIONS

The evidence for a synchronized effort between oncology and palliative medicine is compelling, leading to guidelines statements from prominent oncology and palliative medicine societies. In February 2017, the American Society of Clinical Oncology (ASCO) updated its clinical practice guideline for the integration of palliative medicine into oncology to recommend that all patients with advanced cancer receive palliative medicine services within 8 weeks of their diagnosis and concurrent with active treatment in both the inpatient and outpatient settings.42 Referring patients to multidisciplinary palliative medicine services is optimal. ASCO defines patients with advanced cancer as those with metastasis, late-stage cancer, and/or a prognosis of 24 months or less.42

As part of the Choosing Wisely initiative of the American Board of Internal Medicine, the American Academy of Hospice and Palliative Medicine calls for no delay in palliative care for patients with serious illness who are in any form of distress because they are receiving active treatment.43 Evidence is provided by studies, including randomized controlled trials, that palliative medicine improves pain and symptom control, improves caregiver satisfaction with care, and reduces healthcare costs.43

CONCLUSION

Palliative medicine has an extensive role in oncology beginning when patients are diagnosed, continuing through treatments, and concluding with survivorship or end-of-life care. Oncologists are primary palliative care providers who are responsible for maximizing patient QOL by requesting palliative medicine consultations at the most beneficial time in the cancer trajectory to avoid and relieve patient distress. Patients with any serious illness deserve exceptional symptom management and supportive care. All patients deserve the setting and opportunity to consider and communicate their wishes for advance care planning. Oncologists and palliative medicine providers are intimate colleagues in all of these tasks. Effective collaboration with palliative medicine improves patient outcomes, is cost effective, and has the broad support of clinical research and treatment guidelines.