Friday, November 6, 2015

Palliative in Oncology Symposium 2015 Review

by Kristina Newport

Year 2 of the Palliative in Oncology Conference was a repeat success, with an attendance of over 650 practitioners, more sessions and a new format. A significant difference was the addition of patient advocates who gave their perspective on the topics discussed. Below are some pearls in three main areas, Communication, Symptom Management and Integration of Palliative Care. Check out the Symposium Program for a detailed schedule of the meeting.

COMMUNICATION

The meeting opened with discussion of novel communication aids that incorporate technology to improve communication and shared decision making. James Tulsky MD, known for his work in the area of physician-patient communication, shared a computer based training program that helps oncologists to better respond to negative emotions, a program that will soon be available for all US oncology trainees. He pointed out that “See one, Do one, Teach one” only works if you have somewhere to look, and effective communication education includes observation, practice and goal-directed feedback.

Dr. Vicki Jackson's slide on integration
Areej El-Jawahri MD presented her impressive work showing seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers.

Angelo Volandes MD MPH further emphasized the benefit of visual aids, introducing the ACP Decisions video library, including an informative (and free) video to introduce palliative care that made me want to receive palliative care immediately, despite being healthy! Joanna Paladino MD described her work on the Serious Illness Conversation guide. The work demonstrates that a tool to prompt conversations reduces patient anxiety while facilitating discussions in the setting of serious illness.

Paula Rauch, MD and Kathi Mooney PhD, RN discussed the effect of illness on children and the need to intentionally communicate and care for them in these instances. We were reminded “Just be honest” is not quite enough guidance for parents and children want to know when a parent’s death is approaching. I also loved hearing of the “Living Legacy” where friends and family plan ahead to be a part of special moments in the child’s life, ensuring a piece of the lost loved one lives on.

SYMPTOM MANAGEMENT

Howard McLeod, PharmD gave an informative talk that, if not already convinced, left me certain that Palliative Clinicians need to be well-versed in the role of bio-markers in patient care. He discussed the tailoring of treatments for effectiveness and side effects, and translating the science into something that is meaningful to the patient. I’m convinced we will all need to review our immunology textbooks so we can keep up with appropriate treatments!

Multiple presentations were given on cachexia, discussing mechanisms and potential treatments. The most promising was Jennifer Temel MD’s work on the ROMANA I and II trials, showing significant increases in lean body mass and body weight in patients with advanced non–small cell lung cancer (NSCLC) and cachexia who used anamorelin (not yet available in US) compared with placebo. Susan McClement, RN, PhD and Charles Loprinzi, MD addressed the patient side of cachexia, reminding us nutrition and hydration carry significant meaning to patients and families. For now, appetite stimulants don’t improve quality or quantity of life, so our role should include a focus on managing expectations.

Another medication we may hear more about is aprepitant, an expensive enti-emetic that helped to decrease cough frequency in lung cancer patients, as shown by Amelie Harle, MD who used their Manchester Cough in Lung Cancer scale for objective measurements in the study.

Brian Schmidt MD discussed mechanisms of cancer pain, noting destruction of tissue and compression of nerves is not the full explanation of cancer related pain. He notes nerve recruitment and increased pain is prognostic, serving as bellwethers and sensors embedded within the cancer. Talks on the use of radiotherapy for malignancy symptoms emphasized the Choosing Wisely initiative elements, with an emphasis on fewer fractions for palliative patients. This sometimes results in the need for retreatment, but does not increase symptoms as some might believe. Alternative treatments were also discussed this year, in a breakout session, with discussion of massage, acupuncture and music therapy.

INTEGRATION OF PALLIATIVE CARE

Marie Bakitas DNSc, APRN, NP-C, AOCN, ACHPN presented the third ENABLE trial showing early, phone based palliative care interventions decreased depression in caregivers and improved survival of advanced cancer patients when instituted early. This adds to the increasing literature that early, integrated palliative care can increase life expectancy, and caregiver stress when initiated in the appropriate patients at the appropriate time.

Kathleen Foley MD took a wider view at integration of palliative care with a look at the worldwide stage, discussing her passion of bringing symptom management to low resource areas, believing “pain control is a human right”.

Dr. Campbell's slide on palliative Care in the ICU
 (Apologies to the man sitting in front of me!)
Margaret Campbell, PhD, RN, FPCN discussed appropriate identification of patients in need of palliative care, opening with a story of a patient for whom she was consulted so late that she asked “Are you consulting me to come and pronounce this patient?!” She advises us to identify patients based on their unmet needs, not based on their risk of dying. She emphasized the role of primary palliative care in the ICU, outlining the necessary elements in Table 3 of their paper, emphasizing advance care planning discussions early in the hospitalization.

Spirituality was touched upon by Michael Balboni and Jonathon Marron, demonstrating the need for the medical team, including the interdisciplinary palliative team, to have direct conversations, since community clergy interactions and hope for miracles tend to increased aggressive care.

A highlight on the second day was Vicki Jackson’s keynote presentation on effective care integration and the co-management model. She emphasized the need for Palliative and Oncology clinicians to understand (and respect!) each other and develop prognostic awareness. She notes that dedicated palliative clinicians may not be available, but other members of the oncology team may play the role of a palliative provider. She asks palliative clinicians not to “vilify the oncologist” (here, here!) and identifies “Prognostic awareness” as a key area for Palliative and Oncology collaboration, emphasizing that is not a one-and-done event, it must develop over time.

As the collaboration of Palliative Care and Oncology increases across the country and the globe, I’m excited to be a part of the conversation by attending and participating in meetings like this one. I hope to see increased participation at next year’s symposium, in San Francisco September 9-10, particularly from members of the interdisciplinary team. Thank you, AAHPM, ASCO, ASTRO and MASCC for another great opportunity to learn and share with our colleagues.

Kristina Newport MD (@kbnewport) practices Hospice and Palliative Medicine in Lancaster, PA where she also spends time running after her children, 4 and 6.

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