Palliative care consultations improve outcomes, but referrals lag

TAMPA – Outpatient palliative care consultations are associated with decreased symptom burden in women with gynecologic malignancies, but American Society of Clinical Oncology recommendations for referral are often ignored, according to retrospective data and a review of patient records.

In one study, 78 patients seen between June 2007 and March 2013 at an outpatient symptom management clinic for follow-up within 90 days of their initial consultation completed a questionnaire at each visit, including the nine-item Edmonton Symptom Assessment System. The responses, along with information from the patients’ charts, showed significant improvements in almost all symptoms over time, Dr. Rachel Ruskin, a clinical fellow at the University of California, San Francisco, reported at the annual meeting of the Society of Gynecologic Oncology.

For example, mean pain, fatigue, anxiety, depression, nausea, drowsiness, and appetite scores decreased between 0.7 and 1.5 points from the median baseline scores (on a 10 point scale). A decline in shortness of breath score also approached significance.

No difference was seen with respect to symptom improvement between patients with and without disease, although there appeared to be a trend toward a difference in anxiety scores, Dr. Ruskin noted.

Patients who were treated with concurrent cancer-directed therapies had improvements in pain and fatigue, but to a lesser extent than did those who did not receive treatment, she said.

Among the 35 patients who attended at least two follow-up visits, the improvements in nausea and shortness of breath seen at the first visit persisted at the second, and symptoms of depression and drowsiness continued to improve at each visit. Of those 35 patients, 58% had ovarian, fallopian tube, or peritoneal cancer; 20% had uterine cancer; and 15% had cervical cancer. Most (81%) had stage III, IV, or recurrent cancer.

Mean age at study entry was 57 years, 85% of patients had disease present, and 62% were undergoing treatment. The vast majority (87%) had received chemotherapy, 30% received radiation, and 8% had undergone surgery.

In patients for whom relevant data were available, there was evidence of mild hematologic, renal, and nutritional compromise, and nearly 25% of these patients had been hospitalized within the prior month.

"Notably, in our cohort the improvement in symptoms cannot be attributed to antineoplastic therapies, since – if anything – treatment by traditional oncologic modalities was associated with less benefit in some symptoms," Dr. Ruskin said, adding that future research should focus on "which aspects of palliative care are effective and by what mechanisms," as this information would be helpful for determining best practices that can be replicated across settings and for designing prospective concurrent standard oncologic and palliative care trials.

"In the meantime, we hope that these data will encourage providers to consider referral to their outpatient palliative care colleagues," she concluded.

Findings from another study presented at the meeting suggest there is some work to do in that regard.

In that study, Dr. Carolyn Lefkowits of the University of Pittsburgh found that oncologists are falling short when it comes to following the 2012 ASCO recommendation to consider early palliative care integration for "any patient with metastatic cancer and/or high symptom burden."

Of 340 women with a gynecologic malignancy who were admitted to a gynecologic oncology service between February 2012 and August 2012, only 32% were referred to palliative care, Dr. Lefkowits said.

The patients had a median age of 62 years, and an equal number had early- and late-stage disease. Nearly 25% had recurrent disease by the end of the study period.

Multivariate logistic regression identified independent predictors of palliative care consultation, including number of admission (odds ratio, 17.4 for greater than three vs. three or fewer admissions), admission for symptom management (OR, 22.0), and death within 6 months (OR, 15.7).

Notably, only 16% of the patients died within 6 months of the last admission during the study period, and although 25% of patients overall were referred to palliative care, 54% of those who died within 6 months were referred, suggesting that most referrals are not made for patients who are early in their disease course.

Furthermore, only 53% of patients with recurrent disease – all of whom should have been considered for palliative care integration based on the ASCO recommendations – were seen for palliative care, including 59% who had received three or more lines of chemotherapy, Dr. Lefkowits said.

The findings suggest that the group of patients referred for palliative care is characterized by high symptom burden and poor prognosis. In fact, most of those referred were likely already at the point where they would be considered hospice eligible, she said.

An analysis of referrals based on each ASCO recommendation category showed that the highest referral rate was for "symptom admission" (79%), and the lowest was for recurrent disease (52%).

"So, although the predictors of consultation are in keeping, I think, with the spirit of the ASCO recommendations, we’re still not comprehensively capturing these high-risk subgroups," Dr. Lefkowits said.

She added that she hopes the findings will serve as a "conversation starter, spurring us to address questions, including which gynecologic oncology patients are most appropriate to target for consistent palliative care referral."

Other questions to consider include which systems might help improve referral rates among those patients and which patients (and at what rates) should be referred for specialized palliative care.

All of the patients in the ASCO categories should be receiving palliative care, but it remains unclear what percentage need specialized palliative care, she said

As for improving the rate of palliative care consultations, Dr. Lois M. Ramondetta of the University of Texas M.D. Anderson Cancer Center, Houston, said during a "lecturette" following the presentations by Dr. Ruskin and Dr. Lefkowits, that "branding" is important.

One study showed that 70% of Americans don’t even know what palliative care is, and many of those who do – including both patients and health care providers – equate palliative care with end-of-life care.

Simply changing the name of the palliative care clinic at M.D. Anderson to the "supportive care clinic" led to a 40% increase in consultations, she said.

Most patients and physicians reacted favorably to the concept of supportive care, she explained, noting that palliative care should be rebranded as an extra layer of support, and it should be offered throughout the treatment process.

Studies consistently show that palliative care provides multiple benefits, including decreased hospital length of stay, fewer intensive care admissions, and reduced costs and need for potentially harmful procedures. Some studies have suggested palliative care is associated with improved overall survival, she said.

A number of efforts to improve palliative care skills and to increase referral for palliative care consultations are underway through both ASCO and the SGO, including a virtual learning collaborative being developed by ASCO, efforts to incorporate palliative care education into training and recertification programs, and the revival of a palliative care task force to address these issues.

Dr. Ruskin, Dr. Lefkowits, and Dr. Ramondetta each reported having no disclosures.

tor@frontlinemedcom.com

TAMPA – Outpatient palliative care consultations are associated with decreased symptom burden in women with gynecologic malignancies, but American Society of Clinical Oncology recommendations for referral are often ignored, according to retrospective data and a review of patient records.

In one study, 78 patients seen between June 2007 and March 2013 at an outpatient symptom management clinic for follow-up within 90 days of their initial consultation completed a questionnaire at each visit, including the nine-item Edmonton Symptom Assessment System. The responses, along with information from the patients’ charts, showed significant improvements in almost all symptoms over time, Dr. Rachel Ruskin, a clinical fellow at the University of California, San Francisco, reported at the annual meeting of the Society of Gynecologic Oncology.

For example, mean pain, fatigue, anxiety, depression, nausea, drowsiness, and appetite scores decreased between 0.7 and 1.5 points from the median baseline scores (on a 10 point scale). A decline in shortness of breath score also approached significance.

No difference was seen with respect to symptom improvement between patients with and without disease, although there appeared to be a trend toward a difference in anxiety scores, Dr. Ruskin noted.

Patients who were treated with concurrent cancer-directed therapies had improvements in pain and fatigue, but to a lesser extent than did those who did not receive treatment, she said.

Among the 35 patients who attended at least two follow-up visits, the improvements in nausea and shortness of breath seen at the first visit persisted at the second, and symptoms of depression and drowsiness continued to improve at each visit. Of those 35 patients, 58% had ovarian, fallopian tube, or peritoneal cancer; 20% had uterine cancer; and 15% had cervical cancer. Most (81%) had stage III, IV, or recurrent cancer.

Mean age at study entry was 57 years, 85% of patients had disease present, and 62% were undergoing treatment. The vast majority (87%) had received chemotherapy, 30% received radiation, and 8% had undergone surgery.

In patients for whom relevant data were available, there was evidence of mild hematologic, renal, and nutritional compromise, and nearly 25% of these patients had been hospitalized within the prior month.

"Notably, in our cohort the improvement in symptoms cannot be attributed to antineoplastic therapies, since – if anything – treatment by traditional oncologic modalities was associated with less benefit in some symptoms," Dr. Ruskin said, adding that future research should focus on "which aspects of palliative care are effective and by what mechanisms," as this information would be helpful for determining best practices that can be replicated across settings and for designing prospective concurrent standard oncologic and palliative care trials.

"In the meantime, we hope that these data will encourage providers to consider referral to their outpatient palliative care colleagues," she concluded.

Findings from another study presented at the meeting suggest there is some work to do in that regard.

In that study, Dr. Carolyn Lefkowits of the University of Pittsburgh found that oncologists are falling short when it comes to following the 2012 ASCO recommendation to consider early palliative care integration for "any patient with metastatic cancer and/or high symptom burden."

Of 340 women with a gynecologic malignancy who were admitted to a gynecologic oncology service between February 2012 and August 2012, only 32% were referred to palliative care, Dr. Lefkowits said.

The patients had a median age of 62 years, and an equal number had early- and late-stage disease. Nearly 25% had recurrent disease by the end of the study period.

Multivariate logistic regression identified independent predictors of palliative care consultation, including number of admission (odds ratio, 17.4 for greater than three vs. three or fewer admissions), admission for symptom management (OR, 22.0), and death within 6 months (OR, 15.7).

Notably, only 16% of the patients died within 6 months of the last admission during the study period, and although 25% of patients overall were referred to palliative care, 54% of those who died within 6 months were referred, suggesting that most referrals are not made for patients who are early in their disease course.

Furthermore, only 53% of patients with recurrent disease – all of whom should have been considered for palliative care integration based on the ASCO recommendations – were seen for palliative care, including 59% who had received three or more lines of chemotherapy, Dr. Lefkowits said.

The findings suggest that the group of patients referred for palliative care is characterized by high symptom burden and poor prognosis. In fact, most of those referred were likely already at the point where they would be considered hospice eligible, she said.

An analysis of referrals based on each ASCO recommendation category showed that the highest referral rate was for "symptom admission" (79%), and the lowest was for recurrent disease (52%).

"So, although the predictors of consultation are in keeping, I think, with the spirit of the ASCO recommendations, we’re still not comprehensively capturing these high-risk subgroups," Dr. Lefkowits said.

She added that she hopes the findings will serve as a "conversation starter, spurring us to address questions, including which gynecologic oncology patients are most appropriate to target for consistent palliative care referral."

Other questions to consider include which systems might help improve referral rates among those patients and which patients (and at what rates) should be referred for specialized palliative care.

All of the patients in the ASCO categories should be receiving palliative care, but it remains unclear what percentage need specialized palliative care, she said

As for improving the rate of palliative care consultations, Dr. Lois M. Ramondetta of the University of Texas M.D. Anderson Cancer Center, Houston, said during a "lecturette" following the presentations by Dr. Ruskin and Dr. Lefkowits, that "branding" is important.

One study showed that 70% of Americans don’t even know what palliative care is, and many of those who do – including both patients and health care providers – equate palliative care with end-of-life care.

Simply changing the name of the palliative care clinic at M.D. Anderson to the "supportive care clinic" led to a 40% increase in consultations, she said.

Most patients and physicians reacted favorably to the concept of supportive care, she explained, noting that palliative care should be rebranded as an extra layer of support, and it should be offered throughout the treatment process.

Studies consistently show that palliative care provides multiple benefits, including decreased hospital length of stay, fewer intensive care admissions, and reduced costs and need for potentially harmful procedures. Some studies have suggested palliative care is associated with improved overall survival, she said.

A number of efforts to improve palliative care skills and to increase referral for palliative care consultations are underway through both ASCO and the SGO, including a virtual learning collaborative being developed by ASCO, efforts to incorporate palliative care education into training and recertification programs, and the revival of a palliative care task force to address these issues.

Dr. Ruskin, Dr. Lefkowits, and Dr. Ramondetta each reported having no disclosures.

tor@frontlinemedcom.com

TAMPA – Outpatient palliative care consultations are associated with decreased symptom burden in women with gynecologic malignancies, but American Society of Clinical Oncology recommendations for referral are often ignored, according to retrospective data and a review of patient records.

In one study, 78 patients seen between June 2007 and March 2013 at an outpatient symptom management clinic for follow-up within 90 days of their initial consultation completed a questionnaire at each visit, including the nine-item Edmonton Symptom Assessment System. The responses, along with information from the patients’ charts, showed significant improvements in almost all symptoms over time, Dr. Rachel Ruskin, a clinical fellow at the University of California, San Francisco, reported at the annual meeting of the Society of Gynecologic Oncology.

For example, mean pain, fatigue, anxiety, depression, nausea, drowsiness, and appetite scores decreased between 0.7 and 1.5 points from the median baseline scores (on a 10 point scale). A decline in shortness of breath score also approached significance.

No difference was seen with respect to symptom improvement between patients with and without disease, although there appeared to be a trend toward a difference in anxiety scores, Dr. Ruskin noted.

Patients who were treated with concurrent cancer-directed therapies had improvements in pain and fatigue, but to a lesser extent than did those who did not receive treatment, she said.

Among the 35 patients who attended at least two follow-up visits, the improvements in nausea and shortness of breath seen at the first visit persisted at the second, and symptoms of depression and drowsiness continued to improve at each visit. Of those 35 patients, 58% had ovarian, fallopian tube, or peritoneal cancer; 20% had uterine cancer; and 15% had cervical cancer. Most (81%) had stage III, IV, or recurrent cancer.

Mean age at study entry was 57 years, 85% of patients had disease present, and 62% were undergoing treatment. The vast majority (87%) had received chemotherapy, 30% received radiation, and 8% had undergone surgery.

In patients for whom relevant data were available, there was evidence of mild hematologic, renal, and nutritional compromise, and nearly 25% of these patients had been hospitalized within the prior month.

"Notably, in our cohort the improvement in symptoms cannot be attributed to antineoplastic therapies, since – if anything – treatment by traditional oncologic modalities was associated with less benefit in some symptoms," Dr. Ruskin said, adding that future research should focus on "which aspects of palliative care are effective and by what mechanisms," as this information would be helpful for determining best practices that can be replicated across settings and for designing prospective concurrent standard oncologic and palliative care trials.

"In the meantime, we hope that these data will encourage providers to consider referral to their outpatient palliative care colleagues," she concluded.

Findings from another study presented at the meeting suggest there is some work to do in that regard.

In that study, Dr. Carolyn Lefkowits of the University of Pittsburgh found that oncologists are falling short when it comes to following the 2012 ASCO recommendation to consider early palliative care integration for "any patient with metastatic cancer and/or high symptom burden."

Of 340 women with a gynecologic malignancy who were admitted to a gynecologic oncology service between February 2012 and August 2012, only 32% were referred to palliative care, Dr. Lefkowits said.

The patients had a median age of 62 years, and an equal number had early- and late-stage disease. Nearly 25% had recurrent disease by the end of the study period.

Multivariate logistic regression identified independent predictors of palliative care consultation, including number of admission (odds ratio, 17.4 for greater than three vs. three or fewer admissions), admission for symptom management (OR, 22.0), and death within 6 months (OR, 15.7).

Notably, only 16% of the patients died within 6 months of the last admission during the study period, and although 25% of patients overall were referred to palliative care, 54% of those who died within 6 months were referred, suggesting that most referrals are not made for patients who are early in their disease course.

Furthermore, only 53% of patients with recurrent disease – all of whom should have been considered for palliative care integration based on the ASCO recommendations – were seen for palliative care, including 59% who had received three or more lines of chemotherapy, Dr. Lefkowits said.

The findings suggest that the group of patients referred for palliative care is characterized by high symptom burden and poor prognosis. In fact, most of those referred were likely already at the point where they would be considered hospice eligible, she said.

An analysis of referrals based on each ASCO recommendation category showed that the highest referral rate was for "symptom admission" (79%), and the lowest was for recurrent disease (52%).

"So, although the predictors of consultation are in keeping, I think, with the spirit of the ASCO recommendations, we’re still not comprehensively capturing these high-risk subgroups," Dr. Lefkowits said.

She added that she hopes the findings will serve as a "conversation starter, spurring us to address questions, including which gynecologic oncology patients are most appropriate to target for consistent palliative care referral."

Other questions to consider include which systems might help improve referral rates among those patients and which patients (and at what rates) should be referred for specialized palliative care.

All of the patients in the ASCO categories should be receiving palliative care, but it remains unclear what percentage need specialized palliative care, she said

As for improving the rate of palliative care consultations, Dr. Lois M. Ramondetta of the University of Texas M.D. Anderson Cancer Center, Houston, said during a "lecturette" following the presentations by Dr. Ruskin and Dr. Lefkowits, that "branding" is important.

One study showed that 70% of Americans don’t even know what palliative care is, and many of those who do – including both patients and health care providers – equate palliative care with end-of-life care.

Simply changing the name of the palliative care clinic at M.D. Anderson to the "supportive care clinic" led to a 40% increase in consultations, she said.

Most patients and physicians reacted favorably to the concept of supportive care, she explained, noting that palliative care should be rebranded as an extra layer of support, and it should be offered throughout the treatment process.

Studies consistently show that palliative care provides multiple benefits, including decreased hospital length of stay, fewer intensive care admissions, and reduced costs and need for potentially harmful procedures. Some studies have suggested palliative care is associated with improved overall survival, she said.

A number of efforts to improve palliative care skills and to increase referral for palliative care consultations are underway through both ASCO and the SGO, including a virtual learning collaborative being developed by ASCO, efforts to incorporate palliative care education into training and recertification programs, and the revival of a palliative care task force to address these issues.

Dr. Ruskin, Dr. Lefkowits, and Dr. Ramondetta each reported having no disclosures.

tor@frontlinemedcom.com