Janet L. Abrahm, MD, FACP, FAAHPM, FASCO
Janet L. Abrahm, MD, FACP, FAAHPM, FASCO, has spent more than half of her oncology career as a palliative care physician. After receiving her medical degree from the University of California, San Francisco (UCSF), in 1973, Dr. Abrahm completed her internship and residency at Massachusetts General Hospital in Boston and later served as Chief Resident at Moffitt HC Hospital of UCSF. She completed her fellowship in hematology/oncology at the Hospital of the University of Pennsylvania in Philadelphia and was a hematologist and medical oncologist there for 20 years before moving on to Dana-Farber Cancer Institute (DFCI) and Brigham and Women’s Hospital, in 2021, to practice palliative care medicine; here she created the first DFCI palliative care service and its first palliative care fellowship. In addition to practicing palliative care at DFCI and Brigham and Women’s Hospital, Dr. Abrahm also serves as Professor of Medicine at Harvard Medical School.
Dr. Abrahm has become a widely recognized leader in the field of supportive care and palliative medicine, serving for nearly a decade on the leadership team of the American Academy of Hospice and Palliative Medicine and helping to craft the first Hospice and Palliative Medicine certifying examination offered by the American Board of Internal Medicine. Over the past 14 years, Dr. Abrahm has participated internationally in the Education in Palliative and End-of-Life (EPEC)-Oncology course as a master teacher and is the author of the Comprehensive Guide to Supportive and Palliative Care for Patients With Cancer (Johns Hopkins University Press; 4th edition).
In recognition of her innovative work in palliative medicine, Dr. Abrahm was the recipient of the Walther Cancer Foundation Supportive Oncology Award presented during the 2024 ASCO Annual Meeting.
In a wide-ranging interview with The ASCO Post, Dr. Abrahm discussed the importance of providing every patient with cancer access to palliative medicine throughout survivorship, how oncologists can become more effective communicators, and strategies to alleviate patients’ suffering at the end of life.
Providing Palliative Care Within Limited Provider Resources
In May 2024, ASCO published an update to its Clinical Practice Guideline for Palliative Care, which calls for every patient with advanced cancer to be treated by a multidisciplinary palliative care team, in addition to the patient’s oncologist, within 8 weeks of diagnosis, concurrent with active treatment.1 Do community cancer centers have the resources to provide palliative care services to patients? What are some of the barriers—and some of the solutions—to oncologists’ management of patients’ symptoms in community settings?
Since the formal recognition of palliative care as a medical subspecialty, in 2006,2 the field has grown to more than 7,600 board-certified palliative care physicians in the United States, and more than 18,000 palliative care–certified nurses,3 but that isn’t nearly enough to serve the increasing number of patients diagnosed with cancer each year.
ASCO’s Clinical Practice Guideline for Palliative Care update is more aspirational than realistic at this time, because there are not enough palliative care physicians to serve the number of cancer survivors who need these services.
“For me, the hardest barrier for oncologists to overcome is the feeling that they have failed their patient if they were unable to cure their patient’s cancer.”— JANET L. ABRAHM, MD, FACP, FAAHPM, FASCO
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Of course, every patient with advanced cancer absolutely deserves the services of a multidisciplinary care team that includes physicians, nurses, social workers, chaplains, and, ideally, pharmacists, which is what we have on our teams at Dana-Farber Cancer Institute and Brigham and Women’s Hospital. But even at our hospitals, it is impossible for our palliative care teams to see every patient with advanced cancer.
A recent study on the use of a machine learning algorithm to identify patients with advanced cancer who could benefit from palliative care found that prognostic machine learning systems could increase early palliative care even with physician resource constraints.4 If additional research in prognostic machine learning systems confirms that artificial intelligence, in the context of limited resources, can facilitate an early palliative care referral to the appropriate patients, palliative care services would be available to more of these high-risk patients with advanced cancer, to maximize their quality of life while helping them identify their goals of care.
A major challenge for community hospitals is that only 60% have a palliative care partner. A solution for the hospitals that don’t have the resources to provide palliative care services would be to partner with an enlightened hospice facility that could offer palliative care consultations for patients in need who are still under active treatment. Another possibility is partnering with major cancer centers to consult virtually with their palliative care teams on a regular basis. These rounds could be hosted by any member of the team, a physician, nurse practitioner, or palliative care social worker.
Improving Patients’ Symptoms in the Curative Setting
Please talk about the importance of patient access to palliative care in early-stage cancer diagnosis to improve physical and psychosocial symptoms in the curative setting.
When people get a cancer diagnosis, it causes a huge psychological trauma as well as spiritual and existential crises. Then patients plunge into treatment and are often reluctant to complain to their oncologist about side effects because they want their oncologist to keep fighting for them. They also don’t want to use the little time during an office visit to talk about their treatment-related symptoms instead of the treatment’s effectiveness against the cancer.
One way to overcome these problems is to have patients fill out a symptom- and pain-level questionnaire (either at home or in the waiting room before the office visit), so the physician knows the symptoms the patient is experiencing and, hopefully, can refer the patient to a palliative care specialist.
Symptom management can be lifesaving for patients with serious problems (either from the cancer or the therapy) that may prevent them from continuing with treatment. We can help with pain or other issues that may delay patients’ normal treatment regimen and keep them on their treatment cycles.
I have also seen studies showing that patients undergoing stem cell transplantation experience less posttraumatic stress disorder, anxiety, and depression—and have an improved quality of life at the end of the 6 months—if they have palliative care intervention concurrent with transplant care.5
Building a Clinical Decision Support System
You are part of a research team that is developing an electronic, rule-based clinical decision support system for electronic health records that leverages national clinical practice guidelines to improve the evaluation and management of symptoms during and after cancer treatment. What’s the status of this tool, and when will it be ready for clinical use?
We received some funding from the Cancer Moonshot to bring together multidisciplinary experts in oncology to write the algorithms for the most common cancer-related symptoms and build an evidence-based clinical decision support system that provides a library of national practice guidelines that considers key clinical scenarios, such as age, platelet count, renal function, etc. Our next step is to integrate the platform into the electronic health record and conduct a feasibility study to see how useful the tool is for physicians and if they will adopt the recommendations presented by a clinical decision support system.
We are excited about the progress we are making with this platform, because it incorporates a basic palliative care system management tool built into the electronic health record that can easily be used by oncologists. I hope the system helps oncologists feel empowered to decrease their patients’ suffering and, in the process, helps physicians experience less compassion fatigue and burnout. The goal is to have the system ready for clinical implementation within 3 years.
Communicating More Effectively With Patients
Research shows that only 5% of patients with advanced cancer with up to 6 months to live have an accurate understanding of their illness, with few reporting having a recent discussion about prognosis with their oncologist.6 What are some effective communication strategies to ensure that patients with advanced cancer understand their prognosis, so their end-of-life wishes are honored, and overly aggressive therapy that prolongs unnecessary pain and suffering is avoided? (See sidebar on “Improving Physician-Patient Communication” above.)
For me, the hardest barrier for oncologists to overcome is the feeling that they have failed their patient if they were unable to cure their patient’s cancer. It is important for oncologists to grieve, given the fact that right now, we don’t have an effective therapy to cure every patient.
For patients with a prognosis of less than 6 months, the number-one statement oncologists should make to those patients is “I will always be your doctor, no matter what,” because often patients think that once treatment stops working, their oncologist will no longer want to see them, and that simply isn’t true. I would also assure patients that palliative care and home hospice care can be provided if needed and again reiterate that you will never abandon them.
After providing information about prognosis, I would ask patients what is important for them to prioritize over the next 6 months and what their life purpose is. To see if patients understand their prognosis, instead of asking them to repeat what they’ve just been told, because to me it feels like a test, I prefer to ask patients, “If you have to call a family member or a friend now, what would you say about what we just talked about?” And these conversations about goals of care and prognosis have to be ongoing.
Addressing Patients’ Suffering
Please talk about the moral dilemma for oncologists when they are asked to help patients end their lives and how that request can exacerbate feelings of burnout.
We have to recognize that patients asking for assistance in death is a cry for help at a specific moment in time and they are suffering. When a patient is asking for medical aid in dying, it can sometimes make physicians feel they failed their patient and are unable to prevent the patient’s suffering, which can add to an already emotionally stressful time and increase feelings of burnout. Also, as you said, the request sets up a moral dilemma for oncologists who have taken an oath to “first do no harm” and to do everything possible to save a patient’s life.
There are many ways we can help patients end their suffering without helping them to end their lives. For example, palliative care can address the physical symptoms of pain, as well as help alleviate patients’ psychological, emotional, and spiritual pain. I advise oncologists to recognize that they have not failed their patient if they get such a request. They can explore with their patient the source of the patient’s suffering and refer the patient to the appropriate services to help alleviate that distress.
DISCLOSURE: Dr. Abrahm receives royalties as an editor for UpToDate and from Johns Hopkins University Press for her book, Comprehensive Guide to Supportive and Palliative Care for 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 42:2336-2357, 2024.
2. García-Baquero Merino MT: Palliative care: Taking the long view. Front Pharmacol 9:1140, 2018.
3. Center to Advance Palliative Care: America’s Readiness to Meet the Needs of People With Serious Illness: 2024 State-by-State Look at Palliative Care Capacity. Available at https://reportcard.capc.org/#:~:text=Since%20the%20formal%20recognition%20of,18%2C000%20palliative%20care–certified%20nurses. Accessed January 17, 2025.
4. He JC, Moffat GT, Podolsky S, et al: Machine learning to allocate palliative care consultations during cancer treatment. J Clin Oncol 42:1625-1634, 2024.
5. Mitchell SA: Palliative care during and following allogeneic hematopoietic stem cell transplantation. Curr Opin Support Palliat Care 12:58-64, 2018.
6. Epstein AS, Prigerson HG, O’Reilly EM, et al: Discussions of life expectancy and changes in illness understanding in patients with advanced cancer. J Clin Oncol 34:2398-2403, 2016.
Improving Physician-Patient Communication
In 2017, ASCO published a new guideline in the Journal of Clinical Oncology outlining the best practices for communicating effectively with patients and their family members.1 The goal of the communication guideline is to provide oncologists with a framework of specific practices. This framework enables them to deliver complex information to patients in a supportive manner and to build on oncology care that is both patient-centered and relationship-centered. In this way, oncologists can gain an understanding of who their patients are and what is important to them, so patients can be more active participants in their care.
Here are a few key guideline recommendations:
- Start conversations with patients by asking what their understanding is of their disease. Collaboratively set an agenda to discuss the issues that are most important to patients and family members, as well as to the clinician.
- Engage in behaviors that foster trust, confidence in the clinician, and collaboration by reviewing the patient’s medical chart in advance of the meeting. Be friendly, but not overly casual; make eye contact; engage in reflective listening; get to know the patient and how cancer has changed the patient’s life; ask about how the patient and family are coping and feeling; and be honest, genuine, and respectful.
- Provide diagnostic and prognostic information tailored to patients’ needs and ensure that patients understand their prognosis and treatment options. Clarify the goals of treatment, including cure vs prolongation of survival vs quality of life, and ensure the care goals align with the patients’ values and priorities. Oncologists should also ask about whether the cost of care is a concern; if it is, specific issues should be addressed directly with patients, or patients should be referred to a financial counselor or social worker for resources.
- Initiate conversations about end-of-life preferences early in the course of incurable illness and then revisit the discussion when there are important changes in the patients’ condition or in the course of their disease.
- Provide patients with all treatment options, including clinical trials or palliative care alone if appropriate. For patients with incurable cancers, discuss the option of starting palliative care simultaneously with active cancer therapy.
In addition to these steps, ASCO’s guideline recommends that communication skills training be made available to oncologists at every level of practice and that training emphasize skills practice and experiential learning using role-play scenarios conducted by trained facilitators and direct observation of patient encounters. The guideline also recommends that skills-practice exercises include structured feedback, so clinicians can learn which of their behaviors are effective and where their performance may need improvement.
REFERENCE
1. Gilligan T, Coyle N, Frankel RM, et al: Patient-clinician communication: American Society of Clinical Oncology Consensus Guideline. J Clin Oncol 35:3618-3632, 2017.
