ASCO Guideline Upgrade Integrates Palliative Care in Standard Oncology Care

The guideline recommends that cancer patients should receive palliative care early and in parallel with their active treatment plan.
Published Online: December 15, 2016
Surabhi Dangi-Garimella, PhD
CANCER PATIENTS SHOULD RECEIVE palliative care early and in parallel with their active treatment plan. Referral to interdisciplinary palliative care teams is optimal and can complement existing palliative care services. Caregivers for patients may be referred to these services. These are the most significant recommendations of the American Society of Clinical Oncology (ASCO)’s Ad Hoc Palliative Care Expert Panel.

The panel worked on the guideline, which has been published in the Journal of Clinical Oncology,1 to update the 2012 ASCO provisional clinical option on integrating palliative care into standard oncology care. The update includes a review of 9 randomized clinical trials (RCTs), 1 quasiexperimental study, and 5 secondary publications from previously reviewed RCTs, all published between March 2010 and January 2016.

The studies included patients with advanced or metastatic disease, patients with early-stage non–small cell lung cancer, and a study that compared early with delayed palliative care. All studies included nurses in the intervention, and 5 studies also included palliative care specialists. All studies included outpatients. The primary outcomes of the trials included quality of life (QOL), symptom relief, psychological outcomes, survival, and satisfaction.

Senior author and guideline co-chair Thomas J. Smith, MD, FACP, FASCO, FAAHPM, professor of palliative medicine and professor of oncology, Johns Hopkins School of Medicine, told Evidence-Based Oncology™ that the publication is only the beginning. “We plan to hold a major education session at the 2017 [ASCO] annual meeting, with an emphasis on how oncologists can use the same techniques and listening skills as palliative care team specialists.” Smith indicated that ASCO University,2 the society’s e-learning website, as well as ASCO’s patient-information website, Cancer.Net,3 already have a lot of this information accessible.

Recommendations

Based on their review of evidence, the panel has developed the following specific recommendations:
  1. Individuals given an advanced cancer diagnosis should be referred to an interdisciplinary team of palliative care consultants early in the course of their disease, in parallel with the active treatment plan.
  2. Patients with advanced cancer should have access to interdisciplinary palliative care teams in the outpatient and inpatient settings.
  3. Palliative care services for patients with advanced cancer may include the following:
a. Building a relationship with the patient and family caregivers

b. Symptom, distress, and functional status management

c. Investigate patient understanding of their disease and diagnosis

d. Clarification of treatment goals

e. Assessment and support of coping needs

f. Assistance with medical decision making

g. Coordination of care with other providers

h. Referrals to other providers as needed
     

        4. Patients who are newly diagnosed with advanced cancer should receive a palliative care consult within 8 weeks of their diagnosis.

        5. For patients who have a high symptom burden or unmet physical or psychosocial needs, outpatient programs should ensure patient access to palliative care clinicians who can complement                         existing program tools.  

        6. Family caregivers caring for patients with cancer, either in the early or advanced stage, should have access to a caregiver-tailored palliative care support, such as telephone coaching, education,               referrals, and face-to-face meetings.

In their paper, the authors emphasize that their evidence review supported guidelines for patients who have advanced cancer and that existing evidence is insufficient to make strong recommendations for individuals given an early-stage disease diagnosis.

Palliation Saves Healthcare Dollars

Palliative and hospice care have had a billing code since 2008, and although physicians and advance care practitioners can bill Medicare for time spent in delivering necessary care, currently, chaplains, social workers, and other participants on the interdisciplinary palliative care team cannot.

Beyond the most important role of palliation—improving the patient’s QOL—it also has a significant impact on the overall cost of care. The first such study, conducted by Kaiser Permanente, in more than 800 patients, found that palliative care in the last stages of life prevented hospital and intensive care without any difference in survival; in fact, there was reportedly better satisfaction and a cost savings of $7550.4 Integrating palliative care saved the Veteran’s Administration 38% in direct costs compared with patients who did not receive palliative care, resulting in a system-wide emphasis on palliation. The average daily total direct hospital costs were reduced by $464 for 606 of the 3321 patients who were receiving palliative care (P <.001).5 

Dissemination of Guidelines and Filling the Gaps

Smith believes that one way of measuring the impact of these guidelines would be via ASCO’s Quality Oncology Practice Initiative, or QOPI,6 which has developed measures on palliative care that ASCO members are using to monitor their practice. “The easiest is to see what percentage are referred, or not, by practitioner. Make it a quality-improvement project.” In his opinion, physician behavior is most influenced when their they are compared with their peers, “If others are doing it to improve quality of care, I will, too.”

The study itself has several limitations, as the authors point out:
  1. Being a fairly new field, research funding is limited and, therefore, outcome data are limited.
  2. The field lacks sufficient studies on palliative care in patients with hematological cancer.
  3. Data on health disparities in palliative care are lacking.
  4. Single-site studies limit their generalizability.


In their paper, the authors also propose a few recommendations to help fill out existing gaps in research around palliation in oncology:
  1. Identification of triggers for palliative care
  2. Inclusion of patients with cancer types that were left out of previous trials, including hematological cancers
  3. Palliative care in patients with early-stage disease and including these patients in clinical trials
  4. Research on family caregivers
  5. Research to identify disparities in palliative care and evidence-based interventions to address disparities.
The authors conclude that while interventional studies support early specialty palliative care referrals for patients with advanced-stage cancer, other triggers should be considered to ensure patients receive prompt referral to specialty palliative care services. Additionally, they emphasize the need for training oncologists in primary palliative care competencies and assessing triggers for palliative care specialty services as part of their routine caregiving to patients and their family caregivers.

Despite efforts, a mental barrier remains around early discus sions on palliative care, among patients, their caregivers, and providers. A chief reason is that people continue to equate palliation with hospice and end-of-life care. When asked about this, Smith, a veteran in this field, said that the evidence speaks for itself. “The data are clear that palliative care is associated with longer survival, not shorter survival. So, if people want to maximize their length and QOL, they should be seeking out palliative care.”

He added, however, that studies have found that hospice care also extends survival. “We want to emphasize that palliative care can be given anywhere along the spectrum. Hospice, if you need it, is the best way to help people lead their lives well until they die. And it might be a longer and better time.”

Smith believes that patients and caregivers need to be kept cognizant of the fact that each of us is mortal and that every disease may not be medically curable. “The goal is to start having discussions when people are still well, so that they can plan. It won’t help those with terrible death anxiety, except to plan. But for most people, having a discussion about what the future might hold, and how to plan for it, is tough but good. I had several of those conversations today.” 
References
  1. 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 [published online October 28, 2016]. J Clin Oncol. doi: 10.1200/JCO.2016.70.1474.
  2. ASCO University website. http://university.asco.org/. Accessed November 20, 2016.
  3. Cancer.Net website. http://www.cancer.net/. Accessed November 20, 2016.
  4. 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(7):993-1000.
  5. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979. doi: 10.1089/jpm.2010.0038.
  6. ASCO Institute for Quality website. http://www.instituteforquality.org/. Accessed November 20, 2016.
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