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Sunday, October 28, 2007

New Palliative Care Journal

A new title has been added to the long list of “Current Opinion” journals, Current Opinion in Supportive and Palliative Care. The full text of the first issue of this quarterly journal is available free. The editors [Sam H. Ahmedzai, Richard J. Gralla and Anthony H. Dickenson] provide the following rationale for this new journal:

“While there is no shortage of original publications of preclinical studies, clinical trials and guidelines, however, there appears to be a void in supportive and palliative care for short, concise, current evidence-based reviews – hence this journal filling that void.”

Three topics or themes will be treated in each issue. It will also have an international bent.

Included in the introductory editorial is a rather good graphic, taken from a previous Ahmedzai article, of supportive care in the cancer continuum. The editorial also states that the journal will not be limited to cancer, but “will embrace the spectrum of chronic and life-limiting illnesses facing societies.”

There continues to be discussion/disagreement in the field about the definitions and boundaries of palliative care. And a different editorial in the same issue states that “until recently, supportive care was seen as a rather unglamorous area.” Ahmedzai et al use the WHO and Multinational Association for Supportive Care in Cancer definitions for palliative care and supportive care, respectively, and cites the distinction between them as

“mainly in the timescale of involvement with the patient (and family carers) –supportive care from the beginning of illness until death or into survivorship; palliative care focusing on the latter stages of life. In addition, supportive care engages head-on with curative, life-prolonging and life-maintaining treatments, whereas palliative care generally works after these have been withdrawn.”

Incidentally, this would also be somewhat at odds with the National Cancer Institute’s approach to both palliative care and cancer survivorship: they both begin at diagnosis and continue throughout the cancer experience.

Interestingly, Yale Cancer Center is currently considering a patient care model which explicitly addresses supportive, survivorship, and palliative needs under one umbrella. The recently opened Survivorship Clinic is a component of the Supportive Care Program. Development of an ambulatory palliative care program, also within the Supportive Care program, is in the late stages of discussion.

Does program development and structure follow definition or vice versa? They probably move hand in hand, and it may not matter, anyway. Local institutional financial conditions and culture probably drive the evolution of individual programs more than do philosophy or a particular conception of palliative, supportive, or survivor care.

Before closing, I would like to recommend 2 other provocative editorials in this first issue of COSPC. The first is a sobering look at cancer pain management and a sharp critique of the palliative care field and its prolonged promotion of the (still) nonevidence-based WHO analgesic ladder. The second is a call to look at the bigger picture of toxicity management from the very wide range of cancer therapies currently available. This will require multidisciplinary research—“getting out of our silos”—as well as multidisciplinary clinical care.

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