Updated in 2016, the ASCO clinical practice guideline on the integration of palliative care into standard oncology care provides evidence-based recommendations to oncology clinicians, patients, family and friend caregivers, and palliative care specialists about providing high-quality care for patients with cancer.1 At the 2017 Palliative and Supportive Care in Oncology Symposium,2 VJ Periyakoil, MD, used the guideline to discuss how and when to apply palliative care. “I find this to be a simple but very elegant tool if you’re thinking about how to incorporate palliative care within your practice for your patient,” said Dr. Periyakoil, Associate Professor of Medicine at the Stanford University School of Medicine, Palo Alto, California. Although not a member of the expert panel that developed the guideline, Dr. Periyakoil is a nationally recognized leader in palliative care.
Caring for Patients With Advanced Cancers
The ASCO guideline recommends referral to interdisciplinary palliative care teams that provide inpatient and outpatient care early in the course of disease, alongside active treatment of their cancer. “The earlier the palliative integration occurs, the better the patients feel, the longer they are going to be alive, and the better they’re going to tolerate cancer treatments,” said Dr. -Periyakoil. However, she noted, research suggests that physicians often refer patients to palliative care too late in their disease. “Physicians tend to be overly optimistic by a factor of 3 when prognosticating for our patients … and by the time they are referred, it’s often too little, too late.”
Who Should Deliver Palliative Care?
The ASCO guideline recommends that palliative care for patients with advanced cancer should be delivered through interdisciplinary palliative care teams, with consultation available in both outpatient and inpatient settings. “I’m very biased here because that’s what I do for a living, but I could not agree with this recommendation more,” said Dr. Periyakoil, who added that, given an aging population and the increased number of patients with cancer, oncologists may have to take on more of the responsibilities of palliative care.
“I’m looking for oncologists to partner with us because there are just not enough palliative care specialists to go around,” she said. “Hopefully, oncologists will be able to provide the primary palliative care and then stratify and refer patients to palliative specialists for those suffering with a heavy burden of pain and other distressing symptoms.”
Defining Palliative Care
According to the ASCO guideline, essential components of palliative care include rapport and relationship building with patient and family caregivers(s); symptoms, distress, and functional status management; exploration of understanding and education about illness and prognosis; clarification and support of coping needs; assistance with medical decision-making; coordination with other care providers; and provision of referrals to other care providers as indicated.
“Every oncologist I know is extremely connected with their patients and their family and vice versa, so rapport should not be an issue,” said Dr. Periyakoil.
I’m looking for oncologists to partner with us because there are just not enough palliative care specialists to go around.— VJ Periyakoil, MD. ©Norbert von der Groeben/Stanford School of Medicine.
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Regarding symptom, distress, and functional status management, however, Dr. Periyakoil emphasized the importance of family, particularly as patients’ ability to care for themselves declines.
“It’s been said, ‘don’t just stage the cancer, stage the patient,’” said Dr. Periyakoil, “but I would add, ‘stage the family,’ as well. If you work with the family, you might find a patient’s ability to tolerate certain treatments is higher (or lower) than you’d otherwise anticipate. It’s important to think of the family and patient as a single caring unit.”
Concerning support of coping needs, Dr. Periyakoil noted that providers are often out of synch with the stress levels of their patients and the timing of that stress, which is why starting palliative care early in the diagnosis process is critical. “For newly diagnosed patients with advanced cancer, the Expert Panel suggests palliative care involvement within 8 weeks of diagnosis,” said Dr. Periyakoil, “but I think this recommendation should be for any patient with cancer, not just those with advanced disease.”
Palliative Care Services to Complement Existing Programs
In patients with cancer and a high symptom burden and/ or unmet physical or psychosocial needs, ASCO recommends that outpatient cancer care programs provide and use palliative care clinicians to deliver palliative care services to complement existing program tools. These supportive care services include nurse navigation, lay navigation, community and home health care, geriatric oncology, psycho-oncology, and pain services.
Early specialty palliative care is the gold standard for patients and their caregivers, and all oncologists should be educated in primary palliative care competencies.— VJ Periyakoil, MD
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“This makes perfect sense,” said Dr. Periyakoil. “Older, frail patients require deep expertise in geriatrics management, especially when dealing with multimorbidity. If cancer is just one of the many conditions a patient is suffering from, that has implications for prognosis. Care becomes a bit more nuanced.”
Interventions for Family Caregivers
According to ASCO’s Expert Panel, for patients with early or advanced cancer for whom family caregivers will provide care, providers may initiate caregiver-tailored palliative care support. This type of support includes coaching, education, referrals, and face-to-face meetings. For family caregivers who are unable to travel to the clinic, telephone support may be offered.
“Any kind of support is going to help,” Dr. Periyakoil observed. “Even simple questions such as ‘what matters most to you?’ or “is there anything we can do to help?’ will open up doors and encourage people to share their problems.”3
Early Specialty Palliative Care Referrals
According to the ASCO Guideline, interventional studies support early specialty palliative care referrals among patients with cancer and their caregivers with advanced-stage malignancies.
“Early specialty palliative care is the gold standard for patients and their caregivers, and all oncologists should be educated in primary palliative care competencies, including documenting advance care planning,”3 said Dr. Periyakoil. “Oncologists should also regularly assess triggers for palliative care specialty services as part of their care to patients with cancer and their caregivers to ensure prompt referrals.”
Palliative Care in Resource-Constrained Settings
In recognizing that palliative care is a global issue, that many settings throughout the world lack palliative care specialists, and that many patients with cancer in resource-constrained settings present with advanced disease where disease-modifying therapy is less available, the ASCO Resource-Stratified Guidelines Advisory Group is developing an ASCO Resource-Stratified Guideline on palliative care in global settings to complement the 2016 ASCO guideline. The guideline will consider how nonspecialists can provide palliative care, among other topics. ■
DISCLOSURE: Dr. Periyakoil reported no conflicts of interest.
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.
3. The Stanford Letter Project. Available at med.stanford.edu/letter.html. Accessed December 1, 2017.