Beginning Palliative Care Earlier May Improve Outcomes

CHICAGO – Oncologists and others who care for cancer patients can improve outcomes by integrating palliative care into standard treatment earlier – even as early as the time of diagnosis, Dr. Charles F. von Gunten said in a plenary session at the Chicago Supportive Oncology Conference.

Doing so would require clinicians to expand their definition of palliative care far beyond the traditional boundaries of hospice, which begins only toward the end of life when other therapies are no longer working, said Dr. von Gunten of the University of California, San Diego, and provost at the Institute for Palliative Medicine at San Diego.

He called on clinicians to rethink the traditional "either-or" approach to cancer treatment – in which care consists of either therapies aimed at reducing or curing the illness or care designed to ease suffering and improve the quality of life – and to adopt a "both-and" model instead that employs both standard therapies and palliative interventions simultaneously.

Dr. von Gunten noted the growing accumulation of data during the past 20 years demonstrating the effectiveness of palliative care.

One recent study, for example, found that early palliative care significantly improved quality of life and mood among patients with metastatic non–small cell lung cancer as compared with standard care (N. Engl. J. Med. 2010;363:733-42). Although significantly fewer patients in the early palliative care group than in the standard treatment group received aggressive end-of-life care (33% vs. 54%, P = .05), median survival was significantly longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P = .02).

"Palliative care delivered by hospice programs in the [United States] is better than standard of care at the end of life," Dr. von Gunten said. "That has been proven. It is the gold standard. We should get rid of this language of 'choice': 'Hospice is a choice if you want it; antibiotics are a choice if you want it; chemotherapy is a choice if you want it.' We’re past that. This is the standard of care, and it should be advocated that way by all of us."

But palliative care still has a way to go before it becomes an integral part of cancer treatment, although some progress has been made, he said. While 98% of NCI-designated cancer centers and 78% of community cancer centers report having palliative care programs, 92% and 74% of these centers, respectively, have at least one palliative care physician on staff (JAMA 2010;303:1054-61).

More sobering, he said, is a 1998 membership survey by the American Society of Clinical Oncologists in which 90% of oncologists reported "trial and error" as their primary source of information about palliative care. "How enthusiastic would you be about a doctor who was going to take out your anus, and you said, 'Doctor, how did you learn about this?' and he said, 'Oh, trial and error,'?" Dr. von Gunten said.

Of those surveyed, 73% said they learned from colleagues and role models. "That's great, except where did colleagues and role models learn? Trial and error," he said. And 38% of oncologists said the most significant source of their information about palliative care was a traumatic experience. The underlying message is that no one is teaching palliative care to oncologists, he said. "We have no sense of some sort of systematic dissemination of information.

"Let us have no more talk of choice – no more 'either-or,'?" he said. "The key is how do we make sure [palliative care] is available for patients as part of comprehensive cancer care."

Dr. von Gunten had no disclosures.

CHICAGO – Oncologists and others who care for cancer patients can improve outcomes by integrating palliative care into standard treatment earlier – even as early as the time of diagnosis, Dr. Charles F. von Gunten said in a plenary session at the Chicago Supportive Oncology Conference.

Doing so would require clinicians to expand their definition of palliative care far beyond the traditional boundaries of hospice, which begins only toward the end of life when other therapies are no longer working, said Dr. von Gunten of the University of California, San Diego, and provost at the Institute for Palliative Medicine at San Diego.

He called on clinicians to rethink the traditional "either-or" approach to cancer treatment – in which care consists of either therapies aimed at reducing or curing the illness or care designed to ease suffering and improve the quality of life – and to adopt a "both-and" model instead that employs both standard therapies and palliative interventions simultaneously.

Dr. von Gunten noted the growing accumulation of data during the past 20 years demonstrating the effectiveness of palliative care.

One recent study, for example, found that early palliative care significantly improved quality of life and mood among patients with metastatic non–small cell lung cancer as compared with standard care (N. Engl. J. Med. 2010;363:733-42). Although significantly fewer patients in the early palliative care group than in the standard treatment group received aggressive end-of-life care (33% vs. 54%, P = .05), median survival was significantly longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P = .02).

"Palliative care delivered by hospice programs in the [United States] is better than standard of care at the end of life," Dr. von Gunten said. "That has been proven. It is the gold standard. We should get rid of this language of 'choice': 'Hospice is a choice if you want it; antibiotics are a choice if you want it; chemotherapy is a choice if you want it.' We’re past that. This is the standard of care, and it should be advocated that way by all of us."

But palliative care still has a way to go before it becomes an integral part of cancer treatment, although some progress has been made, he said. While 98% of NCI-designated cancer centers and 78% of community cancer centers report having palliative care programs, 92% and 74% of these centers, respectively, have at least one palliative care physician on staff (JAMA 2010;303:1054-61).

More sobering, he said, is a 1998 membership survey by the American Society of Clinical Oncologists in which 90% of oncologists reported "trial and error" as their primary source of information about palliative care. "How enthusiastic would you be about a doctor who was going to take out your anus, and you said, 'Doctor, how did you learn about this?' and he said, 'Oh, trial and error,'?" Dr. von Gunten said.

Of those surveyed, 73% said they learned from colleagues and role models. "That's great, except where did colleagues and role models learn? Trial and error," he said. And 38% of oncologists said the most significant source of their information about palliative care was a traumatic experience. The underlying message is that no one is teaching palliative care to oncologists, he said. "We have no sense of some sort of systematic dissemination of information.

"Let us have no more talk of choice – no more 'either-or,'?" he said. "The key is how do we make sure [palliative care] is available for patients as part of comprehensive cancer care."

Dr. von Gunten had no disclosures.

CHICAGO – Oncologists and others who care for cancer patients can improve outcomes by integrating palliative care into standard treatment earlier – even as early as the time of diagnosis, Dr. Charles F. von Gunten said in a plenary session at the Chicago Supportive Oncology Conference.

Doing so would require clinicians to expand their definition of palliative care far beyond the traditional boundaries of hospice, which begins only toward the end of life when other therapies are no longer working, said Dr. von Gunten of the University of California, San Diego, and provost at the Institute for Palliative Medicine at San Diego.

He called on clinicians to rethink the traditional "either-or" approach to cancer treatment – in which care consists of either therapies aimed at reducing or curing the illness or care designed to ease suffering and improve the quality of life – and to adopt a "both-and" model instead that employs both standard therapies and palliative interventions simultaneously.

Dr. von Gunten noted the growing accumulation of data during the past 20 years demonstrating the effectiveness of palliative care.

One recent study, for example, found that early palliative care significantly improved quality of life and mood among patients with metastatic non–small cell lung cancer as compared with standard care (N. Engl. J. Med. 2010;363:733-42). Although significantly fewer patients in the early palliative care group than in the standard treatment group received aggressive end-of-life care (33% vs. 54%, P = .05), median survival was significantly longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P = .02).

"Palliative care delivered by hospice programs in the [United States] is better than standard of care at the end of life," Dr. von Gunten said. "That has been proven. It is the gold standard. We should get rid of this language of 'choice': 'Hospice is a choice if you want it; antibiotics are a choice if you want it; chemotherapy is a choice if you want it.' We’re past that. This is the standard of care, and it should be advocated that way by all of us."

But palliative care still has a way to go before it becomes an integral part of cancer treatment, although some progress has been made, he said. While 98% of NCI-designated cancer centers and 78% of community cancer centers report having palliative care programs, 92% and 74% of these centers, respectively, have at least one palliative care physician on staff (JAMA 2010;303:1054-61).

More sobering, he said, is a 1998 membership survey by the American Society of Clinical Oncologists in which 90% of oncologists reported "trial and error" as their primary source of information about palliative care. "How enthusiastic would you be about a doctor who was going to take out your anus, and you said, 'Doctor, how did you learn about this?' and he said, 'Oh, trial and error,'?" Dr. von Gunten said.

Of those surveyed, 73% said they learned from colleagues and role models. "That's great, except where did colleagues and role models learn? Trial and error," he said. And 38% of oncologists said the most significant source of their information about palliative care was a traumatic experience. The underlying message is that no one is teaching palliative care to oncologists, he said. "We have no sense of some sort of systematic dissemination of information.

"Let us have no more talk of choice – no more 'either-or,'?" he said. "The key is how do we make sure [palliative care] is available for patients as part of comprehensive cancer care."

Dr. von Gunten had no disclosures.