First launched in 2014, the Palliative Care in Oncology Symposium introduced a nascent interdisciplinary approach to the treatment of both the physical and psychological symptoms of cancer to improve disease outcome and quality of life for patients. Today, it has evolved into a leading forum for the presentation of innovative research to address the supportive care needs of patients at every stage of survivorship. Now renamed the Palliative and Supportive Care in Oncology Symposium: Patient-Centered Care Across the Cancer Continuum, the meeting, held on November 16–17, 2018, in San Diego, attracted more than 500 attendees in multidisciplinary specialties, including oncology, nursing, palliative care, social work, and psychiatry, as well as patients, patient advocates, and caregivers from 19 countries, including the United States, Canada, and the United Kingdom.
Four years ago, the conference offered 200 abstracts, and the 2018 meeting offered 260 abstracts. These included a randomized study of how the use of an artificial intelligence–based smartphone app significantly reduced both the severity of pain in patients with metastatic cancers, as well as their hospital admissions,1 and a large trial showing that unexpected adverse events associated with immunotherapies may be more common than previously reported.2 (For more detailed coverage of both studies, see the December 10, 2018, and December 25, 2018, issues of The ASCO Post.)
In the first study, patients with metastatic solid tumors were randomly assigned to the use of a smartphone app or usual care, to determine the app’s impact on pain severity, attitudes toward cancer treatment, and health-care utilization in patients with cancer-related pain. The artificial intelligence–powered app was able to distinguish urgent from nonurgent pain to intercede in real time. Patients using the app received alerts on their smartphones with daily pain management tips and were prompted to submit their pain levels 3 days a week. After 8 weeks, patients who used the app experienced a 20% reduction in pain severity and had nearly a 70% lower risk of pain-related hospital admissions than patients in the control group.
Jennifer S. Temel, MD, Professor of Medicine at Harvard Medical School and Clinical Director of Thoracic Oncology and Director of the Cancer Outcomes Research Program at Massachusetts General Hospital, receives the Walther Cancer Foundation Palliative and Supportive Care in Oncology Endowed Award and Lecture at the 2018 Palliative and Supportive Care in Oncology Symposium. With Dr. Temel are Jamie H. Von Roenn, MD, FASCO, ASCO’s Vice President of Education, Science, and Professional Development;
D. Craig Brater, MD, Vice President of Programs for the Walther Cancer Foundation (left); and Greg L. Pemberton, Chairman of the Walther Cancer Foundation (right). Photo ©ASCO/Todd Buchanan 2018.
In the study investigating immunotherapy-related toxicities, researchers analyzed data from nearly 2,800 patients with non–small cell lung cancer who had received nivolumab, pembrolizumab, or atezolizumab. They found that the frequency of immune-related adverse events related to immune checkpoint inhibitors is higher than reported in the initial trials leading to the U.S Food and Drug Administration approval of these immunotherapies. For example, hypophysitis, a rare condition of the pituitary gland, was reported in 0.6% of patients enrolled in the KEYNOTE-24 trial, which compared pembrolizumab vs chemotherapy, and in 2.4% of patients in this study.
Establishing a New Paradigm in Comprehensive Cancer Care
These abstracts as well as hundreds of others presented at the meeting show how the melding of the fields of palliative care and medical oncology has established a new paradigm in comprehensive cancer care. This has led to the development of evidence-based interventions that improve survival and symptom control in patients with cancer.
“There has been a tremendous evolution in how this meeting is perceived since it was launched 4 years ago,” said Jamie H. Von Roenn, MD, FASCO, ASCO’s Vice President of Education, Science, and Professional Development, and a chief architect of the development of the conference. “At the first meeting, there was acknowledgment of the barriers to collaboration between the fields of palliative care and medical oncology. Now the discussion is focused on how to continue to build a co-management model, backed up by research, that changes the way we practice oncology and improves patients’ experience.”
Sounding the Call to Action
Cosponsored by ASCO, the American Academy of Hospice and Palliative Medicine, the American Society for Radiation Oncology, and the Multinational Association of Supportive Care in Cancer, the meeting included six general sessions, covering such diverse topics as Training Oncology Clinicians in Palliative Care Skills, The Great Opioid Debate, Immunotherapeutic Quandaries, and Financial Toxicity During Treatment and Beyond; two poster sessions; and the second annual presentation of the Walther Cancer Foundation Palliative and Supportive Care in Oncology Endowed Award Lecture. The award was presented to Jennifer S. Temel, MD, Professor of Medicine, Harvard Medical School; Clinical Director of Thoracic Oncology; and Director of the Cancer Outcomes Research Program, Massachusetts General Hospital.
During Dr. Temel’s presentation, “Building a Research Program in Palliative and Supportive Oncology Care,” she discussed how the field of oncology is at a pivotal time in the history of palliative and supportive care research. She stressed the importance of continuing to expand and grow research to provide evidence-based remedies to improve care for patients.
“Everything we do in medicine requires data demonstrating the feasibility and efficacy of the care we provide to patients,” said Dr. Temel. “However, the bar for palliative and supportive care research is much higher than it is for tumor-directed research. First, we have to take available data on what the experiences are of patients and their caregivers and develop new care models and interventions to meet their needs. Next, we have to show that what we have developed is feasible and acceptable to patients, and then we have to determine the efficacy of those interventions. It’s much more difficult to develop and study a supportive care intervention than it is to develop a new drug for lung cancer, for example.”
Adding to the barriers hindering palliative care research are the common misconception that palliative care is solely end-of-life care, an insufficient research infrastructure, and a lack of funding. “Palliative care has not received the same level of recognition as a solid science as tumor-directed research, so research for patient-centered care models is not as well funded,” said Dr. Von Roenn. However, that may be changing, as randomized clinical trials on the integration of oncology and palliative care continue to show unambiguous health gains for patients. These benefits include improved survival and symptom control, less anxiety and depression, reduced use of futile chemotherapy at the end of life, improved patient and family satisfaction as well as quality of life, and better use of health-care resources.
For example, a study presented at the 2017 Palliative and Supportive Care in Oncology Symposium by Wendi G. LeBrett, BA, a medical student at the University of California, San Diego, and her colleagues, investigated the economic impact of palliative care among elderly patients diagnosed with advanced solid tumor cancers, including metastatic lung, colorectal, breast, and prostate cancers. They found that the average total cost of care per patient after receiving palliative care decreased by 28%.3 (For more detailed coverage of this study, see the November 25, 2017, issue of The ASCO Post.)
“If you treat cancer-related symptoms better and sooner, patients don’t have to go to the emergency room or to the hospital for care, and that saves money,” said Dr. Von Roenn. “Seeing the improvement in patient care also increases physician satisfaction, because what we are driven by is the ability to make a difference in our patients’ lives, and palliative care enhances that ability.”
Debating the Risk of Opioid Use to Treat Cancer-Related Pain
The numbers tell the story: according to the Centers for Disease Control and Prevention, from 1999 to 2017, nearly 400,000 people in the United States have died of an opioid overdose, including from both the use of prescription and illicit opioids.4 The result of the opioid crisis plaguing the United States is having a chilling effect on the management of cancer-related pain for both oncologists, who may fear potential legal action, and for patients, who may worry about becoming addicted to the pain medication.
One of the tragic outcomes of the opioid crisis is that physicians are now afraid to prescribe the medication, even when it is the right thing to do.— Jamie H. Von Roenn, MD, FASCO
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How to ensure that patients with long-lasting, chronic pain obtain the relief they need and avoid opioid abuse was the subject of a fiery session on The Great Opioid Debate, with presentations by Charles F. von Gunten, MD, PhD, Vice President of Medical Affairs Hospice & Palliative Medicine OhioHealth Kobacker House, and Leslie J. Blackhall, MD, Section Head of Palliative Care at the University of Virginia School of Medicine, who were asked to offer contrasting viewpoints on the issue. (The ASCO Post delved deeper into the challenges of safely prescribing opioid medications for cancer-related pain and assessing opioid use disorder in cancer survivors in the December 25, 2018, issue.)
“Emotion, not data, is what’s driving the current debate, and it’s hurting patients,” argued Dr. von Gunten. “The evidence base for opioids for moderate to severe cancer pain is firm. We must ensure that professionalism, and not fear, guides oncology practice.”
The prevalence of opioid abuse in the treatment of cancer pain is low among patients, said Dr. von Gunten. He stressed that opioids are safe and effective for cancer-related pain and remain the mainstay in its management.
Although Dr. Blackhall agreed that opioids are the mainstay of cancer-related pain management, she countered that a cancer diagnosis does not mean that a patient is exempt from a substance use disorder. “In the general population, there is a pretty high risk of substance use disorder, and patients with cancer are people. Patients with cancer and their family members are both at risk,” she said.
To confront the issue directly, Dr. Blackhall recommends that clinicians employ a strategy of universal screening, universal monitoring, and universal education in how to use opioids safely and to utilize the Opioid Risk Tool (www.drugabuse.gov/sites/default/files/files/OpioidRiskTool.pdf) to assess the risk for opioid abuse among patients being treated for chronic pain.
“One of the tragic outcomes of the opioid crisis is that physicians are now afraid to prescribe the medication, even when it is the right thing to do,” said Dr. Von Roenn. “The threat of legal action against physicians has changed the way they practice medicine, and the fear is that we will undertreat patients who have serious cancer pain. There are a lot of unnecessary barriers being put up to prevent appropriate opioid prescribing. Although there are risks involved in prescribing opioids, we have to do better at understanding and managing those risks.”
From the Patient Perspective
Included among the highlights at the 2018 Palliative and Supportive Care in Oncology Symposium was the Keynote Lecture, “Making the Most of a Life, Interrupted: A Young Adult Perspective on Cancer,” presented by Suleika Jaouad, who was diagnosed with myelodysplastic syndrome and acute myeloid leukemia at age 22.
Suleika Jaouad delivers the Keynote Lecture on “Making the Most of a Life, Interrupted: A Young Adult Perspective on Cancer,” at the 2018 Palliative and Supportive Care in Oncology Symposium. Photo ©ASCO/Todd Buchanan 2018.
Ms. Jaouad, who is the author of the “Life, Interrupted” column in The New York Times, described the unique set of challenges young adult cancer survivors face. They include ongoing physical, social, psychological, and financial distress as well as the importance of self-advocating to receive the best survivorship care. She also urged providers to listen to their patients and allow patients’ experiences to inform the work they do.
Looking Ahead
Future Palliative and Supportive Care in Oncology Symposiums will build on the research framework now established to move the integration of oncology and palliative care forward to improve patient care. “We want this meeting to present research that will change both how clinicians practice cancer care and how patients experience that care,” said Dr. Von Roenn. ■
DISCLOSURE: Drs. Von Roenn and Blackhall reported no conflicts of interest. Dr. Temel has received institutional research funding from Pfizer. Dr. von Gunten has received honoraria from Salix, Otsuka, and AstraZeneca; is a consultant/advisor for AstraZeneca; is on the speakers bureau for Salix; and has given expert testimony for Progenics Pharmaceuticals, Salis, and Valeant.
REFERENCES
1. Kamdar MM, Centi AJ, Fischer N, et al: A randomized controlled trial of a novel artificial-intelligence based smartphone application to optimize the management of cancer-related pain. 2018 Palliative and Supportive Care in Oncology Symposium. Abstract 76. Presented November 16, 2018.
2. Cathcart-Rake EJ, Sangaralingham LR, Shah N, et al: Immunotherapy-related toxicities: More common than originally reported? 2018 Palliative and Supportive Care in Oncology Symposium. Abstract 184. Presented November 17, 2018.
3. LeBrett WG, Roeland E, Bruggman A, et al: Economic impact of palliative care among elderly cancer patients. 2017 Palliative and Supportive Care in Oncology Symposium. Abstract 91. Presented October 27, 2017.
4. Centers for Disease Control and Prevention: Opioid overdose: Understanding the epidemic. Available at www.cdc.gov/-drugoverdose/epidemic/index.html. Accessed January 17, 2019.
