ASCO: Discuss Palliative Care, Symptom Relief With Cancer Patients Early

Oncologists should initiate difficult discussions about palliative care and symptom relief throughout the course of an illness, and not wait until the end stage to discuss these options with patients who have advanced cancers, according to a new policy statement self-described as a "clarion call" from the American Society of Clinical Oncology.

"There is a need to change the paradigm for advanced cancer care to include an earlier and more thorough assessment of patients’ options, goals, and preferences, and to tailor the care that we deliver to these individual needs throughout the continuum of care," Dr. Jeffrey M. Peppercorn of Duke University Medical Center in Durham, N.C., and his coauthors wrote in the statement published online in the Journal of Clinical Oncology.

Too often the transition from a focus on disease-directed treatment to an emphasis on palliative care comes within days of the end of life, they noted (J. Clin. Oncol. 2011 Jan. 24 [doi:10.1200/JCO.2010.33.1744]). "This is a clarion call for oncologists as individual practitioners, and for our profession in general, to take the lead in curtailing the use of ineffective therapy and ensuring a focus on palliative care and relief of symptoms throughout the course of illness."

ASCO has also released a new guide to help start difficult discussions about end-of-life care with advanced cancer patients. "Central to all of these goals is the need for realistic conversations about options and alternatives that should occur throughout the course of the patient’s illness." Such conversations may currently occur in fewer than 40% of patients with advanced cancer, the authors observed.

"This statement is also a call to action to clinical researchers and funding sources to support research into physician- and patient-based barriers to individualized advanced cancer care and to support evaluation of interventions to overcome barriers to this care," they added, calling for improved training in communication issues and in palliative care, reimbursement for advanced care planning, and increased support for relevant research.

The statement is an important move toward changing care patterns for patients with advanced disease, Dr. Diane E. Meier, director of the Center to Advance Palliative Care, commented in an interview. "It’s a big step in the right direction because this is the prestigious oncology physician organization, which is drawing a line in the sand to its membership and saying that we’ve got to do better," she said. "The data suggest that in many types of cancer, people referred to hospice live substantially longer" than do those who are not referred.

There is a "virtual absence of undergraduate and graduate medical education in the core primary competencies of palliative medicine, including the basics of pain and symptom management, the identification and treatment of depression and other mood disorders, and the identification of and intervention for distressed family caregivers," said Dr. Meier. "Those things are simply absent from curriculum. So I do think that it’s odd that we expect doctors to do things that they’ve never been taught."

The pool of palliative care physicians currently in practice is small and overworked, she added. "It’s easy to say that every patient should get comanagement with palliative care. The problem is ... there are very few palliative care specialists around. Those who are around are overwhelmingly busy in the hospital," Dr. Meier said, adding that "the question of how to actually implement this approach to care of comanagement and concurrent management by oncologists and palliative care specialists is vexing, and not really addressed in the ASCO report or anywhere else."

In particular, reimbursement will have change in order to better integrate palliative care into the management of patients. "Quite logically, doctors and other providers do what they get paid to do and really cannot afford to sustain a practice doing things that are essentially nonreimbursed," said Dr. Meier, a professor of geriatrics and palliative medicine at the Mount Sinai School of Medicine in New York.

"If we continue to move toward these new delivery and payment models [accountable care, medical homes, and bundling], there will be strong financial incentives to integrate palliative care in all settings" because it will be too costly not to, she noted.

The statement authors and Dr. Meier reported that they have no relevant financial relationships.

Oncologists should initiate difficult discussions about palliative care and symptom relief throughout the course of an illness, and not wait until the end stage to discuss these options with patients who have advanced cancers, according to a new policy statement self-described as a "clarion call" from the American Society of Clinical Oncology.

"There is a need to change the paradigm for advanced cancer care to include an earlier and more thorough assessment of patients’ options, goals, and preferences, and to tailor the care that we deliver to these individual needs throughout the continuum of care," Dr. Jeffrey M. Peppercorn of Duke University Medical Center in Durham, N.C., and his coauthors wrote in the statement published online in the Journal of Clinical Oncology.

Too often the transition from a focus on disease-directed treatment to an emphasis on palliative care comes within days of the end of life, they noted (J. Clin. Oncol. 2011 Jan. 24 [doi:10.1200/JCO.2010.33.1744]). "This is a clarion call for oncologists as individual practitioners, and for our profession in general, to take the lead in curtailing the use of ineffective therapy and ensuring a focus on palliative care and relief of symptoms throughout the course of illness."

ASCO has also released a new guide to help start difficult discussions about end-of-life care with advanced cancer patients. "Central to all of these goals is the need for realistic conversations about options and alternatives that should occur throughout the course of the patient’s illness." Such conversations may currently occur in fewer than 40% of patients with advanced cancer, the authors observed.

"This statement is also a call to action to clinical researchers and funding sources to support research into physician- and patient-based barriers to individualized advanced cancer care and to support evaluation of interventions to overcome barriers to this care," they added, calling for improved training in communication issues and in palliative care, reimbursement for advanced care planning, and increased support for relevant research.

The statement is an important move toward changing care patterns for patients with advanced disease, Dr. Diane E. Meier, director of the Center to Advance Palliative Care, commented in an interview. "It’s a big step in the right direction because this is the prestigious oncology physician organization, which is drawing a line in the sand to its membership and saying that we’ve got to do better," she said. "The data suggest that in many types of cancer, people referred to hospice live substantially longer" than do those who are not referred.

There is a "virtual absence of undergraduate and graduate medical education in the core primary competencies of palliative medicine, including the basics of pain and symptom management, the identification and treatment of depression and other mood disorders, and the identification of and intervention for distressed family caregivers," said Dr. Meier. "Those things are simply absent from curriculum. So I do think that it’s odd that we expect doctors to do things that they’ve never been taught."

The pool of palliative care physicians currently in practice is small and overworked, she added. "It’s easy to say that every patient should get comanagement with palliative care. The problem is ... there are very few palliative care specialists around. Those who are around are overwhelmingly busy in the hospital," Dr. Meier said, adding that "the question of how to actually implement this approach to care of comanagement and concurrent management by oncologists and palliative care specialists is vexing, and not really addressed in the ASCO report or anywhere else."

In particular, reimbursement will have change in order to better integrate palliative care into the management of patients. "Quite logically, doctors and other providers do what they get paid to do and really cannot afford to sustain a practice doing things that are essentially nonreimbursed," said Dr. Meier, a professor of geriatrics and palliative medicine at the Mount Sinai School of Medicine in New York.

"If we continue to move toward these new delivery and payment models [accountable care, medical homes, and bundling], there will be strong financial incentives to integrate palliative care in all settings" because it will be too costly not to, she noted.

The statement authors and Dr. Meier reported that they have no relevant financial relationships.

Oncologists should initiate difficult discussions about palliative care and symptom relief throughout the course of an illness, and not wait until the end stage to discuss these options with patients who have advanced cancers, according to a new policy statement self-described as a "clarion call" from the American Society of Clinical Oncology.

"There is a need to change the paradigm for advanced cancer care to include an earlier and more thorough assessment of patients’ options, goals, and preferences, and to tailor the care that we deliver to these individual needs throughout the continuum of care," Dr. Jeffrey M. Peppercorn of Duke University Medical Center in Durham, N.C., and his coauthors wrote in the statement published online in the Journal of Clinical Oncology.

Too often the transition from a focus on disease-directed treatment to an emphasis on palliative care comes within days of the end of life, they noted (J. Clin. Oncol. 2011 Jan. 24 [doi:10.1200/JCO.2010.33.1744]). "This is a clarion call for oncologists as individual practitioners, and for our profession in general, to take the lead in curtailing the use of ineffective therapy and ensuring a focus on palliative care and relief of symptoms throughout the course of illness."

ASCO has also released a new guide to help start difficult discussions about end-of-life care with advanced cancer patients. "Central to all of these goals is the need for realistic conversations about options and alternatives that should occur throughout the course of the patient’s illness." Such conversations may currently occur in fewer than 40% of patients with advanced cancer, the authors observed.

"This statement is also a call to action to clinical researchers and funding sources to support research into physician- and patient-based barriers to individualized advanced cancer care and to support evaluation of interventions to overcome barriers to this care," they added, calling for improved training in communication issues and in palliative care, reimbursement for advanced care planning, and increased support for relevant research.

The statement is an important move toward changing care patterns for patients with advanced disease, Dr. Diane E. Meier, director of the Center to Advance Palliative Care, commented in an interview. "It’s a big step in the right direction because this is the prestigious oncology physician organization, which is drawing a line in the sand to its membership and saying that we’ve got to do better," she said. "The data suggest that in many types of cancer, people referred to hospice live substantially longer" than do those who are not referred.

There is a "virtual absence of undergraduate and graduate medical education in the core primary competencies of palliative medicine, including the basics of pain and symptom management, the identification and treatment of depression and other mood disorders, and the identification of and intervention for distressed family caregivers," said Dr. Meier. "Those things are simply absent from curriculum. So I do think that it’s odd that we expect doctors to do things that they’ve never been taught."

The pool of palliative care physicians currently in practice is small and overworked, she added. "It’s easy to say that every patient should get comanagement with palliative care. The problem is ... there are very few palliative care specialists around. Those who are around are overwhelmingly busy in the hospital," Dr. Meier said, adding that "the question of how to actually implement this approach to care of comanagement and concurrent management by oncologists and palliative care specialists is vexing, and not really addressed in the ASCO report or anywhere else."

In particular, reimbursement will have change in order to better integrate palliative care into the management of patients. "Quite logically, doctors and other providers do what they get paid to do and really cannot afford to sustain a practice doing things that are essentially nonreimbursed," said Dr. Meier, a professor of geriatrics and palliative medicine at the Mount Sinai School of Medicine in New York.

"If we continue to move toward these new delivery and payment models [accountable care, medical homes, and bundling], there will be strong financial incentives to integrate palliative care in all settings" because it will be too costly not to, she noted.

The statement authors and Dr. Meier reported that they have no relevant financial relationships.