Updated ASCO Recommendations Support Early Palliative Care in Patients with Advanced Cancers

Karna W. Morrow, CPC, RCC, CCS-P, PCS
Senior Consultant, CSI Coding Strategies, Inc, Powder Springs, GA
Sheryl A. Riley, RN, OCN, CMCN
Managing Partner
Clarion, LLC
Bernardsville, NJ

Patients with advanced cancer should receive early palliative care concurrently with active standard disease treatment, according to the updated guidelines from the American Society of Clinical Oncology (ASCO), which were recently published in the Journal of Clinical Oncology.1 An expert panel convened by ASCO concluded that early palliative care in patients with advanced cancers reduces depression and improves satisfaction with care and quality of life.

Systematic Review

The multidisciplinary panel undertook a systematic review that updated the 2012 ASCO provisional clinical opinion on the integration of palliative care into standard oncology care. The 2012 panel highlighted the need for additional research into the impact that palliative care has on patient outcomes. The 2012 panel noted, “While a survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings, substantial evidence demonstrates that palliative care—when combined with standard cancer care or as the main focus of care—leads to better patient and caregiver outcomes.”2

The 2016 expert panel used a growing body of evidence to determine the benefits of early palliative care in advanced cancers. The panel reviewed 9 randomized clinical trials and 1 quasi-experimental clinical trial that was published between March 2010 and January 2016, as well as 5 secondary randomized clinical trial analyses that were reviewed for the 2012 ASCO provisional clinical opinion on the integration of palliative care into standard oncology care. The primary outcomes included quality of life, symptom relief, psychological outcomes, survival, and patient satisfaction.

Patients with advanced cancer were defined as those who had distant metastases, late-stage disease, life-limiting cancer, or those with a survival prognosis of 6 to 24 months.

The Key Recommendations

The updated guidelines include 5 key recommendations for patients with advanced cancers:

  1. Patients should be referred to palliative care teams that provide inpatient and outpatient care early together with active treatment of their cancer
  2. Palliative care should be delivered through interdisciplinary palliative care teams, with consultation in outpatient and inpatient settings
  3. Patients should receive palliative care services, which may include a referral to a palliative care provider
  4. Cancer care outpatient programs should provide and use dedicated resources to deliver palliative care services to patients with a high symptom burden and/or unmet physical or psychosocial needs (to complement existing supportive care programs)
  5. For patients with early or advanced cancer for whom family caregivers will provide care in outpatient, home, or community settings, other providers (eg, nurses, social workers) may provide caregiver-tailored palliative care support, which could include telephone coaching, education, referrals, and face-to-face meetings.

Recommendation 1 was based off of supplementary evidence that has been reported since the 2012 ASCO provisional clinical opinion on the integration of palliative care into standard oncology care was released, which supports the integration of early interdisciplinary palliative care services for all patients with advanced cancer. No adverse outcomes with the early use of palliative care services were reported in any of the studied clinical trials.

In addition to the general benefits observed with integrating early palliative care, several large clinical trials found that early palliative care at the end of life of patients with lung cancer reduced the use of chemotherapy and increased the enrollment rates in hospice care.

According to Recommendation 2, palliative care should be offered in outpatient and inpatient settings.

“Although palliative care delivery models for oncology patients are varied, the unifying elements among successful models include a palliative care provision by an interdisciplinary team available as a consultation service, with a presence in the outpatient as well as inpatient setting,” the panel noted.

Palliative care teams include palliative care physicians, nurses, and in some cases, social workers, chaplains, and rehabilitation specialists. In the clinical trials, the majority of successful models took place within an oncology clinic, allowing for better communication between the palliative care team and the oncology team.

Successful palliative care consultations assess patients’ baseline quality of life and physical, psychological, spiritual, and social domains and prognosis, with ongoing assessments.

According to Recommendation 3, the following components are essential to palliative care:

  • Building a relationship with patients and families
  • Managing symptoms, such as pain, fatigue, or sleep disturbance, and monitoring distress and functional status
  • Providing education about the patient’s disease and prognosis, and clarifying treatment goals
  • Assessing coping needs
  • Providing assistance with decision-making
  • Coordinating with and providing referrals to other providers.

To accomplish these goals, palliative care services need to be tailored to each patient’s needs. Palliative care appointments should evolve throughout the illness trajectory, with more time-intensive, rapport-building appointments in the beginning, and discussions concerning end-of-life care after a relationship has been established.

In addition, the panel recommends that newly diagnosed patients with advanced cancer should start palliative care early, ideally within 8 weeks of being diagnosed. Research indicates that palliative care does not impede oncology care, but rather complements it, helping patients reach their treatment goals.

In Recommendation 4, the panel suggests that patients with cancer with a high symptom burden and/or unmet physical or psychosocial needs should receive palliative care services to complement existing supportive care programs. Based on the systematic review, no clinical trial compared whether palliative care programs were different from or better than other service programs, although it was clear that palliative care services enhanced the benefits to patients throughout their treatments.

“Offering palliative care across the continuum should complement existing supportive care programs (eg, social work, pain management, pastoral care) and may serve to ensure coordination and communication across these services,” the panel noted.

Recommendation 5 highlights the need for family caregivers who provide care in outpatient, home, or community settings to receive palliative care support. This can include telephone coaching, education, referrals, and face-to-face meetings.

Current evidence suggests that early palliative care can lower a caregiver’s levels of depression, stress, caregiver burden, and psychological distress, although the evidence is stronger for family caregivers of patients with advanced cancers than for caregivers of patients with early-stage cancer.

The panel noted that although this recommendation is evidence-based, the quality of evidence is low, and the recommendation is considered weak.

Cost Implications

Increased cost should not be a concern when providing palliative care, the panel concluded. Palliative medicine is reimbursed in the United States as a medical subspecialty, which physicians and nurse practitioners can bill for; however, other members of a palliative care team (ie, chaplains and social workers) cannot bill for palliative care services.

In addition, numerous studies have shown that palliative care reduces the total cost of care and can be a means to provide “better care at a cost we can afford,” the panel agreed.


References

  1. Ferrell BR, Temel JS, Temin S, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2016;35:96-112.
  2. Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion. J Clin Oncol. 2012;30:880-887.

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