Tuesday, February 7, 2017
The American Society of Clinical Oncology recently published the strongest call for concurrent palliative care in oncology. Released online on Halloween 2016, and published in the Journal of Clinical Oncology just last month, this Clinical Practice Guideline (CPG) should be in the pocket of every palliative care team as they meet with their oncology colleagues to collaborate on better care for patients.
The guideline holds more weight and expands the scope compared to the 2012 Provisional Clinical Opinion which emerged after the Temel article. In 2010, NEJM published a randomized control trial (RCT) of palliative care in metastatic non-small cell lung cancer (NSCLC). Many people (outside of palliative care and within the field) focused on the secondary outcome that palliative care might prolong life. That mania often overshadowed the primary outcome which demonstrated that palliative care provided concurrently could improve the quality of life (QOL) of patients, dispelling the common barrier because oncologists ‘already do this.’ (See Lyle Fettig’s excellent analysis here.)
The 2012 PCO focused more on symptom burden and QOL, Instead of focusing on the survival benefit secondary outcome of Temel, they emphasized lack of harm. They did pull from other key studies including Bakitas (ENABLE), Brumley (in-home PC), Meyers (patient/caregiver dyads), and Rabow (outpatient clinics). The 2016 Expert Panel looked at 16 total studies to come up with the 6 areas of focused recommendations for the CPG, which are:
- Effective symptom control
- Practical models of palliative care
- Defining palliative care in oncology
- Relation of palliative care to existing/emerging services
- Interventions for caregivers
- Which patients benefit and at what time in illness
(A quick sidebar on definitions. Advanced cancer includes those with distant metastases, late-stage disease, or cancer that is life-limiting and/or with a prognosis of 6-24 months. There was a specific lack of focus on end of life as a criterion. ASCO defined palliative care in this guideline as: patient and family-centered care that optimizes quality of life by anticipating, preventing and treating suffering. Palliative care throughout the continuum of illness involves addressing physical intellectual emotional, social and spiritual needs, in addition to facilitating patient autonomy, access to information and choice.)
Will this new guideline change practice?
History may give you a reason to be cynical. Palliative care has been trying to get upstream with oncology for a LONG time. Surprisingly, the 2012 Provision Clinical Opinion and Temel study had no impact on the 2013 NCCN Guidelines for lung cancer (0 mentions of palliative care in 100 pages). But with studies like Al-Jawhari's Palliative Care in Stem Cell Transplantation and the growth of the Palliative Oncology conference, things may be changing. In addition, value-based payment models like the Oncology Care Model emphasize QOL.
So go download this open access PDF, read it, make sure you are doing the best evidence palliative care you can do, discuss it with your palliative care colleagues and only THEN when you have your ducks in a row, go talk with your oncology peers and see what beautiful things you can create together.
Christian Sinclair, MD, FAAHPM is a palliative care doctor at the University of Kansas, editor of Pallimed, and really loves doing outpatient care in the oncology clinic.