Growing awareness of the benefits of palliative care in patients with cancer has prompted ASCO to update its recommendations for clinicians, patients, caregivers, and health-care organizations on integrating palliative care in oncology.1 The updated guideline reinforces prior recommendations in the 2016 guidelines on early integration of palliative care in oncology while expanding the role of palliative care into patient populations who are often underserved: patients with hematologic malignancies and those in early-phase clinical trials.2
Betty Ferrell, PhD
“This is a pivotal time,” said Betty Ferrell, PhD, of City of Hope and guideline Expert Panel Co-Chair. “This guideline is a call to action for everyone to think about how they are integrating palliative care for all patients with cancer. There are great advances in cancer care, but none of these will be fully effective unless we fully integrate palliative care.”
The guideline Expert Panel consisted of a multidisciplinary group with expertise in medical and radiation oncology, hematology, and palliative care, as well as a patient representative. Members reviewed 52 randomized controlled trials that compared palliative care interventions and measured outcomes such as quality of life and psychosocial measures.
Reinforcing the Benefit of Early Integration of Palliative Care
Despite a growing understanding of the importance of palliative care, there remains a stigma among both patients and clinicians that palliative care is synonymous with “giving up,” Dr. Ferrell said. Many patients are not referred to palliative care until the last few weeks of life, but early integration of palliative care can not only alleviate symptoms but also improve treatment outcomes.3-6
The updated guideline reinforces previous recommendations that patients with cancer be referred to palliative care early in their treatment course. However, they don’t set a specific time point from diagnosis.
Justin Sanders, MD, MSc
Justin Sanders, MD, MSc, of McGill University, in Canada, and guideline Expert Panel Co-Chair, noted the updated recommendation is meant to provide flexibility to health-care systems as they navigate how to efficiently allocate their resources. “As we learn more about the benefits of palliative care for noncancer populations, palliative care resources are being stretched in new ways,” Dr. Sanders said. “The 2016 guideline had a recommendation around specific timelines for integrating palliative care that isn’t always easy to make a reality in an evolving health-care landscape.” The Expert Panel reviewed new research on precision palliative care to promote a more targeted and efficient approach to palliative care.7
Integrating Palliative Care Into Hematology-Oncology
Patients with hematologic malignancies may suffer from severe symptoms but also have significant responses to treatment that enable them to live for many years. Dr. Sanders explained that some oncologists may be hesitant to refer these patients to palliative care because they worry it would interfere with potentially life-saving treatment. The guideline cites three new publications since the 2016 guideline demonstrating the benefit of palliative care in patients with hematologic malignancies.8-10
“These updated guidelines stress that we need to do better for these patients,” Dr. Ferrell said. “The Panel recognized that data are limited in this population, but there’s no question that patients with hematologic malignancies have a lot of symptoms and quality-of-life concerns.”
Providing Palliative Care to Patients on Early-Phase Clinical Trials
A second population who is often excluded from palliative care includes patients on early-phase clinical trials. These patients have often exhausted other treatment options and are on trials as a last option, even though the chance of personally benefiting from the trial is very low, Dr. Ferrell explained. The updated guideline urges oncologists to address the quality-of-life concerns of these patients, despite a lack of controlled trials.
“There aren’t a lot of studies done in this area,” Dr. Ferrell said. “Clinicians are often focused on the clinical trial, which is so vital to advancing cancer care, but it is also important that these patients receive palliative care. It’s our responsibility as oncology clinicians and researchers to support these patients while they’re helping us support the science.”
Future Research Needed on Implementation
Drs. Ferrell and Sanders agreed that the benefit of palliative care is well established. Dr. Sanders hopes new research and future guidelines can start to explore the most effective ways to implement palliative care.
Dr. Sanders hopes future studies will investigate the best ways to further integrate palliative care into oncology but recognized that randomized controlled trials, which are often considered the gold standard on which to base any guideline recommendation, are difficult to do in this setting. Diverse research methods will help potentially capture the patient experience and design palliative care for all patients with cancer.
REFERENCES
1. Sanders JJ, Temin S, Ghoshal A, et al: Palliative care for patients with cancer: ASCO guideline update. J Clin Oncol. May 15, 2024 (early release online).
2. 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.
3. Zimmermann C, Swami N, Krzyzanowska M, et al: Early palliative care for patients with advanced cancer: A cluster-randomised controlled trial. Lancet 383:1721-1730, 2014.
4. Ferrell B, Sun V, Hurria A, et al: Interdisciplinary palliative care for patients with lung cancer. J Pain Symptom Manage 50:758-767, 2015.
5. Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733-742, 2010.
6. Grudzen CR, Richardson LD, Johnson PN, et al: Emergency department-initiated palliative care in advanced cancer: A randomized clinical trial. JAMA Oncol 2:591-598, 2016.
7. Sedhom R, Shulman LN, Parikh RB: Precision palliative care as a pragmatic solution for a care delivery problem. J Clin Oncol 41:2888-2892, 2023.
8. El-Jawahri A, LeBlanc T, VanDusen H, et al: Effect of inpatient palliative care on quality of life 2 weeks after hematopoietic stem cell transplantation: A randomized clinical trial. JAMA 316:2094-2103, 2016.
9. El-Jawahri A, LeBlanc TW, Kavanaugh A, et al: Effectiveness of integrated palliative and oncology care for patients with acute myeloid leukemia: A randomized clinical trial. JAMA Oncol 7:238-245, 2021.
10. El-Jawahri A, Traeger L, Greer JA, et al: Effect of inpatient palliative care during hematopoietic stem-cell transplant on psychological distress 6 months after transplant: Results of a randomized clinical trial. J Clin Oncol 35:3714-3721, 2017.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, May 15, 2024. All rights reserved.
