Dr. Sharlene Gill (biography and disclosures)
What care gaps have been identified?
Patients with advanced cancer are faced with disease that cannot be cured. Treatment considerations include ‘active’ disease-directed therapy aimed to slow tumour growth, symptom management and palliative or supportive care. Oncologists often view their primary goal as improving survival and, hence, directing active therapy. Unfortunately, the transition from a focus on active, disease-directed treatment to palliative care often occurs late, commonly within just days to weeks of the end of life. Honest and candid conversations about prognosis and establishing goals of care can be difficult and as a consequence may be delayed, which can hinder access to quality palliative care for the patient and support for their caregivers. Analysis of patterns of care suggests that patients are increasingly receiving chemotherapy and requiring more frequent visits to the hospital and emergency department in the last 2 weeks of life, and are often referred to hospice only in the very last days of life. (1)
Data that answers these gaps
In a recent randomized trial published in the New England Journal of Medicine, patients with advanced lung cancer who received both chemotherapy and also received care and support from a palliative care team immediately after their diagnosis lived almost three months longer than those who received chemotherapy alone. (2) Improved patient-MD communication has been associated with a better understanding of prognosis, a greater likelihood of seeking hospice care and reduced likelihood of pursuing futile therapy before death.(3) In addition, as reported in another related study in the Journal of Clinical Oncology, caregivers of patients with advanced, terminal disease who receive palliative therapy experience less emotional stress (4).
What recommendations are suggested?
The American Society of Clinical Oncology recently published a guidance to direct individualized care for patients with advanced cancer.(5) This statement advocates for candid discussions which provide disease-directed and supportive care options for patients with advanced cancer throughout the continuum of care. While patients may wish to pursue any possible anticancer treatment even in the last weeks of life, such decisions need to be informed with a realistic assessment of prognosis and limitations of treatment. In individualized circumstances, consideration may be given to participation in clinical trials; however it is important to ensure that such participation is aligned with a patient’s personal goals and preferences. When no reasonable therapeutic options exist, patients should be encouraged to transition to palliative care to maximize their quality of life. Beyond providing cancer-directed therapies, it is the responsibility of the care provider team (including oncologists and GPs) to restrain from the use of ineffective therapies and to ensure that patients are given the opportunity to benefit from palliative care through the course of their illness and to spend their final days with dignity and peace of mind.
References: You can request articles from CPSBC https://www.cpsbc.ca/library/library-article-requests or log in with your UBC ID.
- Earle CC, Landrum MB, Souza JM, et al: Aggressiveness of cancer care near the end of life: is it a quality-of-care issue? J Clin Oncol 26:3860-3866, 2008 (View article)
- Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non small-cell lung cancer. N Eng J Med 363: 733-742, 2010 (View article )
- Robinson TM, Alexander SC, Hays M, etal: Patient-oncologist communication in advanced cancer: Predictors of patient perception of prognosis. Support Care Cancer 16:1049-1057, 2008 (View article with UBC)
- Wright AA, Keating NL, Balboni TA, et al: Place of death: Correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health. J Clin Oncol 28:4457-4464, 2010 (View article )
- Peppercorn JM, Smith TJ, Helft PR etal: American Society of Clinical Oncology Statement: Toward Individualized Care for Patients with Advanced Cancer. J Clin Oncol 29:755-760, 2011 (View article with UBC)
Useful link:
Practice Support Program End of Life module (PSP EOL module)
http://www.gpscbc.ca/psp/learning
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I agree with the approach discussed, however, when you live in a community with no cancer agency it can often be difficult to get a clear sense of prognosis and initiating this discussion w/o a clear sense of this can be hard, especially if the family is not ready.
I definitely agree with providing good supportive care during active oncology treatments. I would caution that the increased survival seen in the Temel study needs to be duplicated in other studies before we can really assess the effect of early palliative care on overall survival.
Good article. Working in hospital now this approach seems to make much more sense
Family docs need to take a more directive role earlier in the course of terminal disease so that patients do not feel compelled to persue what is often futile oncology treatment that diminishes quality EOL care.
I completely agree with the above statement, even though it seems self evident
today i was faced with a patient with inoperable pancreatic cancer who i had already started on fentanyl patches, domperidome, referred to palliative care and who will receive a celiac plexus block within the next few days and heart breakingly she tells me she hope to retire at 65. she is 62 I don’t want to keep hitting her with the reality of her imminent death
very useful advice there is nosubstitue for truthful facts hopefully the patient will appreciate this approach
While families often try to shield their loved ones regarding terminal diagnoses, I find that once communication is initiated, patients can actively engage in end-of-life decisions. I fully support the views expressed here.
Although late in joining here, I do agree that GP’s need to always bring up earlier than later a discussion/clarification of limits to aggressive oncology therapy in anyone at the stage of advanced cancer. They must be supported in their decision to cease and desist with the realistic preparation for their “personal affairs.” Even if they hope for longer time and therapy which the GP will need to support if they so wish, the reminders of the limits possible should continue to be broached.
Many GPs don’t have the training in palliative care to feel confident in dealing with end of life discussions. There must be more CME available for primary physicians.