ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care and that all patients should have the opportunity to participate. Patients in clinical trials may benefit from the support of palliative care.

— Betty R. Ferrell, PhD, and colleagues

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As reported in the Journal of Clinical Oncology, ASCO has released a clinical practice guideline update on integration of palliative care into standard oncology care.¹ This update of a 2012 ASCO provisional clinical opinion² is based on an Expert Panel’s systematic review of data reported between 2010 and January 2016; nine randomized trials, one quasi-experimental trial, and five secondary analyses of randomized trials used for the 2012 provisional statement provided evidence for the update. The panel was co-chaired by Betty R. Ferrell, PhD, of City of Hope Medical Center; Thomas J. Smith, MD, of Sidney Kimmel Comprehensive Cancer Center; and Jennifer S. Temel, MD, of Massachusetts General Hospital.

The updated recommendations are summarized here. The type of recommendation, evidence quality, and strength of recommendation are shown in brackets.

Key Recommendation

Patients with advanced cancer, whether inpatient or outpatient, should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referring patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs. Providers may refer caregivers of patients with early or advanced cancer to palliative care services.

Specific Recommendations

Patients with advanced cancer should be referred to interdisciplinary palliative care teams (consultation) that provide inpatient and outpatient care early in the course of disease, alongside active treatment of their cancer. [Type: evidence based, benefits outweigh harms; evidence quality: intermediate; strength of recommendation: strong]

Palliative care for patients with advanced cancer should be delivered through interdisciplinary palliative care teams, with consultation available in both outpatient and inpatient settings. [Type: evidence based, benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate]

Patients with advanced cancer should receive palliative care services, which may include referral to a palliative care provider. Essential components of palliative care may include:

• Rapport and relationship building with patients and family caregivers
• Symptom, distress, and functional status management (eg, pain, dyspnea, fatigue, sleep disturbance, mood, nausea, or constipation)
• Exploration of understanding and education about illness and prognosis
• Clarification of treatment goals
• Assessment and support of coping needs (eg, provision of dignity therapy)
• Assistance with medical decision-making
• Coordination with other care providers
• Provision of referrals to other care providers as indicated.

For newly diagnosed patients with advanced cancer, the expert panel suggests early palliative care involvement within 8 weeks of diagnosis. [Type: informal consensus, benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate]

Among patients with cancer with a high symptom burden and/or unmet physical or psychosocial needs, outpatient cancer care programs should provide and use dedicated resources (palliative care clinicians) to deliver palliative care services to complement existing program tools. [Type: evidence based, benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate]

For patients with early or advanced cancer for whom family caregivers will provide care in the outpatient setting, nurses, social workers, or other providers may initiate caregiver-tailored palliative care support, which could include telephone coaching, education, referrals, and face-to-face meetings. For family caregivers who may live in rural areas and/or are unable to travel to the clinic and/or longer distances, telephone support may be offered. [Type: evidence based; evidence quality: low; strength of recommendation: weak]

The panel notes that the guideline uses the National Consensus Project definition of palliative care: “Palliative care means 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 and to facilitate patient autonomy, access to information, and choice.”³ The panel further states: “ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care and that all patients should have the opportunity to participate. Patients in clinical trials may benefit from the support of palliative care.”

ASCO is currently developing a resource-stratified guideline on providing palliative care in settings where palliative care teams are not available, primarily, but not limited to low- and middle-income countries. ■

Disclosure: For full disclosures of the study authors, visit www.jco.ascopubs.org.

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 35:96-112, 2017.

2. Smith TJ, Temin S, Alesi ER, et al: American Society of Clinical Oncology provisional clinical opinion: The integration of palliative care into standard oncology care. J Clin Oncol 30:880-887, 2012.

3. Dahlin C: Clinical practice guidelines for quality palliative care (ed 3). Pittsburgh, PA, National Consensus Project for Quality Palliative Care, 2013.