Commentary (Von Roenn): Improving Palliative and Supportive Care in Cancer Patients

Despite major advances in cancer biology and therapeutics, cancer and its treatment continue to cause devastating suffering, not only for the more than half a million patients who will die this year from cancer, but also for many of those who will be successfully treated.[ 1] Symptom burden has a profound impact on the quality of life of cancer patients across all stages of dis ease. Routine screening of ambulatory cancer patients identifies an average of 7 to 10 distressing physical and psychological symptoms per patient.[2] Even patients with a good performance status have a median of nine or more symptoms.[3,4] Not surprisingly, the severity and burden of symptoms near the end of life is even greater.[4] Currently available symptom management strategies, if widely imple mented, could relieve much of this suffering.[5] Furthermore, in spite of evidence that early diagnosis and treatment of at least some symptoms (pain and delirium, for example) may prevent symptom progression, symptom management remains inadequate. Khatcheressian and colleagues address the reasons for this failing and highlight some suggestions for practical solutions. Additional concerns include the lack of adequate education in symptom management and palliative care, a dearth of role models, and the dichotomy between palliative and cure-oriented care. Shortcomings in Training
Inadequate training of physicians in symptom management, communication skills, and palliative care principles remains a major barrier to excellent palliative and end-of-life care.[6-8] A 1998 survey of oncologists, conducted by the American Society of Clinical Oncology (ASCO) to assess their education in end-oflife and palliative care, reported serious shortcomings in the training and current clinical practice of a large proportion of respondents.[6] Less than one-third of those surveyed reported their formal training to be "very helpful" in communicating with dying patients, coordinating their care, shifting to palliative care or initiating hospice care. Fewer than half found their training "very helpful" in managing the symptoms of patients who were dying. The compelling need to improve palliative care education for oncologists is highlighted by the survey's finding that traumatic patient experience ranked higher as a source of learning than did lectures during fellowship. Additionally, more than half of respondents identified "trial and error in clinical practice" as one important source of learning about endof- life care. Role models are another essential component of training in palliative and end-of-life care.[9,10] Forty-five percent of oncologists ranked role models during fellowship as important to their training, and yet a dearth of palliative care role models exists.[6] The need for greater education in communication skills and care for the dying was underscored by the substantial number of respondents who reported a sense of failure when a patient became terminally ill and significant anxiety when faced with follow-up meetings with dying patients.[6] Improvements in Education
Fortunately, these deficiencies in training are beginning to be addressed through multiple programs. For example, the Education for Physicians on End-of-Life Care for Oncologists (EPEC-O) Program, jointly sponsored by the National Cancer Institute, ASCO, and EPEC, held its first trainthe- trainer program in June. This workshop included five plenary sessions and 12 modules that combined didactic sessions, videotape presentations, interactive discussions, and practical exercises. The workshop demonstrated effective teaching techniques based on adult learning theory and presented a curriculum of core palliative care principles for oncology. The Center to Advance Palliative Care (CPAC), referred to by Khatcheressian and colleagues, is another superb educational resource, providing practical training for the development of palliative care programs. Inadequate Symptom Management
Inadequate training results in underrecognition and inadequate treatment of symptoms.[11-17] A striking example of inadequate symptom management is the treatment of pain in patients with metastatic cancer.[14-17] Cleeland et al reported that 40% of patients with pain at Eastern Cooperative Oncology Group (ECOG) institutions were not prescribed analgesics strong enough to match the severity of their pain.[14] Despite national and international guidelines for cancer pain management, many patients are not prescribed appropriate analgesics.[14-16] It is clear, as noted by the authors, that before pain can be appropriately treated, it must be appreciated, and it is frequently not assessed. Similarly, we continue to underdiagnose and undertreat the debilitating psychological symptoms (depression, anxiety, and delirium) associated with cancer and, most notably, with advanced disease.[ 12,13,18-22] Integration of Palliative Principles
One additional barrier to improving palliative care for cancer patients is the dichotomy between palliative care and cure-oriented care.[23] Patients are frequently offered only cureoriented treatment or palliative therapy. Indeed, the World Health Organization (WHO) once defined palliative care as, "The active total care of patients whose disease is not responsive to curative treatment."[24] More recently, however, this definition has been extended to focus on the need for integration of palliative principles throughout the course of cancer, noting that "many aspects of palliative care are also applicable earlier in the course of illness, in conjunction with anticancer treatment."[24] This is particularly important as advances in therapy have led to prolongation of survival for many patients with incurable cancer, increasing the population of patients living with cancer as a chronic, debilitating illness and underscoring the need to integrate palliative care throughout the course of cancer care.

Disclosures:

The author(s) have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1. Jemal A, Murray T, Samuels A, et al: Cancer statistics, 2003. CA Cancer J Clin 53:5-26, 2003. 2. Portenoy RK, Thaler HT, Kornblith AB, et al: Symptom prevalence, characteristic and distress in a cancer population. Qual Life Res 3:183-189, 1994.
3. Komaroff AL: Symptoms: In the head or in the brain? Ann Intern Med 134:783-785, 2001.
4. Walsh D, Donnelly S, Rybicki L: The symptoms of advanced cancer: relationship to age, gender, and performance status in 1,000 patients. Support Care Cancer 8:175-179, 2000.
5. Field MJ, Cassel CK (eds) for the Committee on Care at the End of Life, Division of Health Care Services, Institute of Medicine: Approaching Death: Improving Care at the End of Life. Washington, DC, National Academy Press, 1997.
6. Emanuel EJ, National Cancer Institute, unpublished data, 2000.
7. Weissman DE, Block SD, Blank C, et al: Recommendations for incorporating palliative care education into the acute care hospital set ting. Acad Med 74:871-877, 1999.
8. Weissman DE, Block SD: ACGME requirements for end-of-life training in selected residency and fellowship programs: a status report. Acad Med 77:299-304, 2002.
9. Weissman DE: Cancer pain education: a call for role models. J Clin Oncol 6:1793-1794, 1988.
10. Weissman DE, Dahl JL: Update on the cancer pain role model education program. J Pain Symptom Manage 10:292-297, 1995.
11. Cassel CK, Foley KM: Principles for Care of Patients at the End of Life: An Emerging Consensus Among the Specialties of Medicine. New York, Milbank Memorial Fund, 1999.
12. Breitbart W, Rosenfeld B, Pessin H, et al: Depression, hopelessness and desire for hastened death in terminally ill patients with cancer. JAMA 284:2907-2911, 2000.
13. Hirschfeld RM, Keller MB, Panico S, et al: The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA 277:333- 340, 1997.
14. Cleeland CS, Gonin R, Hatfield AK, et al: Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 330:592-596, 1994.
15. Von Roenn JH, Cleeland CS, Gonin R, et al: Physician attitudes and practice in cancer pain management. A survey from the Eastern Cooperative Oncology Group. Ann Intern Med 119:121-126, 1993.
16. Cleeland CS, Gonin R, Baez L, et al: Pain and treatment of pain in minority patients with cancer. The Eastern Cooperative Oncology Group Minority Outpatient Pain Study. Ann Intern Med 127:813-816, 1997.
17. Stiefel F, Holland J: Delirium in cancer patients. Int Psychogeriatr 3:333-336, 1991.
18. Carroll BT, Kathol R, Noyes R, et al: Screening for depression and anxiety in cancer patients using the hospital anxiety and depression scale. Gen Hosp Psychiatry 15:69-74, 1993.
19. Holland JC: Preliminary guidelines for the treatment of distress. Oncology 11:109-114, 1997.
20. Holland JC (ed): Psycho-Oncology. New York, Oxford University Press, 1998.
21. Holland JC: NCCN practice guidelines for the management of psychosocial distress. Oncology 13:113-147, 1999.
22. Holland JC, Almanza J: Giving bad news: Is there a kinder, gentler way? Cancer 86:738-740, 1999.
23. Foley KM, Gelband H (eds): Improving Palliative Care for Cancer: Summary and Recommendations. Institute of Medicine and National Research Council. Washington, DC, National Academy Press, 2001.
24. World Health Organization. Cancer Pain Relief and Palliative Care. Technical Report Series 804. Geneva, Switzerland, World Health Organization, 1990.