With treatment advances, there are now fewer absolutes in managing locally advanced NSCLC, according to Dr. Reckamp. “We are moving toward treating performance status 2 patients, and obviously, that is a heterogeneous group of people,” she elaborated. “For those who need a lot of care, you need to see how much of it is due to their tumor burden that you may be able to reverse with chemotherapy, vs somebody who you are just going to make sicker. And that’s still the art of medicine.”

Most patients with performance status 3 will not be able to tolerate chemotherapy or radiation therapy. But those who have an adenocarcinoma should be tested for EGFR mutations and ALK translocation because they could still benefit from EGFR tyrosine kinase inhibitors or crizotinib (Xalkori). “That might be one thing that I would do for a performance status 3 patient, other than just trying to move forward with palliative care and hospice…,” she said. “Those drugs can drastically change outcomes even for patients with performance status 3 and potentially in performance status 4.”

Palliative Care Considerations

When it comes to early integration of palliative care, Dr. Reckamp acknowledged concerns about difficulty in getting health insurers to cover chemotherapy once patients start palliative care. “ASCO is trying to find a way for the majority of practices to integrate palliative care with oncology care.”

Studies like the one from the Massachusetts General Hospital showing that using palliative care while patients are receiving chemotherapy reduces costs should be helpful. “I don’t know that we are there completely, but there is a dedication to trying to move the field forward that way and educate people. And now you have some data to argue with the insurance company and say, wait a minute, I need to [involve palliative care]; look, this may save you money in the end,” she concluded. ■