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)
Practice Support Program End of Life module (PSP EOL module)