Important Research in the Palliative Care of Patients With Cancer
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– John Smith, MD
The emphasis at this year’s Palliative Care in Oncology Symposium, held earlier this month in Boston, was on patient-centered care throughout the cancer continuum. The meeting attracted more than 650 attendees and included six general sessions featuring best practices in communication, nonpharmacologic interventions for pain, and systems integration; two oral sessions; and two poster sessions. The symposium attracted an international audience with attendees participating from the United States, Canada, United Kingdom, France, Italy, and China, among other countries.
Sponsored by ASCO, the American Academy of Hospice and Palliative Medicine (AAHPM), the American Society for Radiation Oncology (ASTRO), and the Multinational Association of Supportive Care in Cancer (MASCC), this year’s symposium included about 250 abstracts. Highlights from some of the presentations are provided below.
Watch future issues of The ASCO Post for more from the Palliative Care in Oncology Symposium, and be sure to visit http://video.ascopost.com (The ASCO Post Newsreels) to view interviews with experts recorded live during the meeting.
Identifying Patients With Cancer Who Are Most at Risk of Death
Determining the answer to a simple question, “Would you be surprised if this patient died within the next year?” may be an important tool to help predict which patients with cancer may be in their final year of life, according to the findings from the study by Vick et al.1 The tool, known as the “Surprise Question,” was found to be more accurate in predicting the risk of cancer death within 1 year than other factors such as cancer type, stage, the age of the patient, or time from diagnosis.
From July 2012 to October 2014, researchers at Ariadne Labs enrolled 81 oncology clinicians, including oncologists (59), nurse practitioners (18), and physician assistants (4), from Dana-Farber Cancer Institute in Boston, into a randomized trial. The trial investigated the impact of a structured intervention to improve conversations about end-of-life goals among patients with cancer.
The clinicians answered the Surprise Question—“Would you be surprised if this patient died within the next year?”—regarding nearly 5,000 patients, aged 19 to 95 with all types and stages of cancer, as the first step in Ariadne Labs’ patient-centered Serious Illness Care Program. Of the 4,617 patients for whom the researchers had complete data, 3,821 (83%) answered “Yes” to the Surprise Question and 796 (17%) answered “No.” The propensity-adjusted 1-year survival rate for “Yes” patients was 93% (95% confidence interval [CI] = 91%–96%) compared to 53% (95% CI = 46%–60%) for the “No” patients (P < .0001).
The Surprise Question was more predictive of patient death than other factors, including type of cancer, age of the patient, cancer stage, or time since diagnosis.
A Simple, Effective Tool
“There is no generally accepted tool to identify seriously ill patients who would benefit from conversations about their values, goals, and priorities,” said Judith Vick, a medical student at the Johns Hopkins University School of Medicine in Baltimore, and lead author of this study, during a press briefing about the study results.
“The Surprise Question is a simple tool that allows clinicians to identify those patients,” she continued. “It is a simple, affordable, and available tool that is easily implemented. Our results show that oncology clinicians’ own judgment using the Surprise Question identified about 60% of patients with a short life expectancy. However, given that 40% of these patients were not identified by the Surprise Question, more research is needed to understand why.”
Putting the Data Into Context
Commenting on the study results, ASCO expert and moderator of the press briefing, Don S. Dizon, MD, Clinical Co-Director of Gynecologic Oncology at Massachusetts General Hospital, Boston, said, “This important work shows that one question that clinicians actually ask themselves may be more effective than the usual clinical and laboratory parameters to identify patients who have a risk of dying within a year. I think this is important, especially in an era where we are looking at values and preferences regarding current and future cancer care and I look forward to future results of this multipronged intervention.”
Collaboration Improves Care for Patients With Advanced Cancer
An innovative service model that partners radiation oncology with palliative care leads to better results for patients, according to a new analysis. The model of care, established at Mount Sinai Medical Center, New York, is one of only a handful in the country. The study was presented at the Palliative Care in Oncology Symposium in Boston.2
Since its implementation in 2013, the service has led to shorter durations of radiation treatment, fewer unfinished radiation treatments, shorter hospital stays, and increased use of palliative care services. Based on these preliminary findings, the authors suggest that better integration of palliative medicine into the care of patients with advanced cancer undergoing radiation therapy improves outcomes for patients, their families, and hospital systems.
Whole-patient assessments and family meetings are critical parts of the new multidisciplinary service model. During these encounters, a careful evaluation of patients’ physical symptoms as well as psychosocial, spiritual, lifestyle, and logistical concerns is performed. Overall goals of care are discussed in an open and compassionate way.
In addition to radiation oncologists, medical oncologists, and palliative care specialists, family meetings may include representatives from social work, nursing, chaplaincy, and family members, all of whom play vital roles in a patient’s decision-making.
“Our study validates the importance of cohesive collaboration in cancer care. As a palliative radiation oncologist, tackling pain is only a small part of what I do. My role extends to engage patients and families in conversations that help distill their priorities and set realistic expectations of treatment. Partnering with palliative care helps us incorporate goals and preferences into our care plans,” said Kavita Dharmarajan, MD, Assistant Professor of Radiation Oncology and Palliative Medicine at Mount Sinai Medical Center. “When we work together, patients receive a higher quality of care that focuses on the whole person, not just a tumor.”
The service model is available to all patients with any type of cancer receiving radiation for palliative purposes, whether it is for metastases in the bone, brain, lungs, pelvis, or any other organ system in the body. The current study focused on patients with painful bone metastases.
Researchers examined charts of patients with advanced cancer who received palliative radiation therapy for painful bone metastases. The study included 175 patients treated before the new service started and 161 treated after the new service was established.
This study showed that judicious use of shorter and more efficient radiation treatments within the new service model led to patients spending fewer days hospitalized. The new service decreased the median length of hospital stay from 18 to 12 days and halved the proportion of radiation treatments that went unfinished (15% vs 8%). Under the new service model, more patients received palliative care services within a month of finishing their treatment (49% vs 34%).
Benefits of the New Model
According to the authors, these findings are important because the great majority of patients appreciate being able to spend more time outside of the hospital, particularly as they near the end of life. The support from palliative care services allowed patients and families to manage symptoms at home.
The new service more than doubled the use of single-fraction radiotherapy and short-course radiotherapy from 26% to 61%. Patients were also more likely to complete their radiation treatment.
Before the new model was established, many patients received radiation treatments lasting 2 weeks or longer. At times, patients who are very sick do not survive long enough after completion of therapy to see its benefits. This occurred more frequently when patients underwent longer radiation treatments before the new service model was established.
Importantly, increasing the use of shorter palliative radiation treatments did not compromise the pain relief provided by the treatment. In fact, there was a slight increase in the percentage of patients who reported pain improvement (80% vs 74%) within the new service model, although the difference was not statistically significant.
“This study reinforces the importance of integrating palliative care throughout treatment,” said Dr. Dizon. “The results serve as welcome evidence that we can achieve better care for patients through cooperation across disciplines.” ■
Disclosure: Drs. Dharmarajan and Dizon and Ms. Vick reported no potential conflicts of interest.
1. Vick JB, Pertsch N, Hutchings M, et al: The utility of the surprise question in identifying patients most at risk of death. Palliative Care in Oncology Symposium. Abstract 108. Presented October 9, 2015.
2. Chang S, Smith CB, Dharmarajan KV, et al: A palliative radiation oncology consult service’s impact on care of advanced cancer patients with symptomatic bone metastases. Palliative Care in Oncology Symposium. Abstract 110. Presented October 9, 2015.