The Oncologist as Primary Palliative Care Provider

There has been much progress in our “war on cancer,” launched with President Nixon’s signing of the National Cancer Act in 1971. In 2011, however, it is estimated that more than 571,000 people will die from cancer.[1] Because of advances in cancer detection and treatment, along with an increasing general awareness about various cancers, patients and families experiencing cancer no longer view themselves as “victims.” Patients surviving cancer often deal with multiple complications and challenging long-term sequelae of what for many has become a chronic disease. For cancer survivors, comprehensive approaches to the assessment of their condition require attention to the physical, emotional, social, and spiritual domains of the illness experience, as described by palliative care and hospice pioneer Cecily Saunders. Attention to these domains of care, and alleviation of the human suffering experienced along the cancer trajectory, is embodied in the palliative care approach.[2]

Von Roenn and Temel nicely lay out the rationale for integrating palliative care approaches into mainstream oncologic care, and they provide data for the efficacy of palliative care and so-called supportive care interventions, in particular for patients with advanced stage lung cancer.[3,4] Useful distinctions between primary, secondary, and tertiary forms of palliative care have also been made by von Gunten.[5] Primary palliative care is defined as “basic skills and competencies required of all physicians and other healthcare professionals.” For physicians, primary palliative care is about the kind of doctoring that approaches medical care in a framework acknowledging cancer and other serious illnesses as diseases afflicting thinking, feeling persons, which is attentive to management goals and counseling that respects all four domains of the sickness experience. Secondary palliative care refers to practices of “specialist clinicians and organizations that provide consultation and specialty care,” while tertiary palliative care refers to practices of academic medical centers where research and training programs define and provide the evidentiary base for advances in the specialty.[5] Oncologists clearly operate in all three realms of palliative care, but one can argue that since they serve as primary care physicians for many, if not most cancer patients, there should be an emphasis on the skills and competencies of primary palliative care in the education and training of oncologists.

But which of primary palliative care skills are of most importance in the context of management of patients with advanced cancer? In this and other articles, Temel and colleagues provide helpful templates and descriptions to operationalize the practices of primary palliative care interventions for oncologists.[6,7] The importance of symptom management as a core competency in oncologic palliative care is clear, particularly for patients with high symptom burden and lower quality of life scores. It is important to note, however, that primary palliative care for the oncologist must be much more than symptom management, and this is acknowledged by Von Roenn, Temel, and others. Emphasizing a focus on maintaining and improving quality of life considerations of the patient in all domains-physical, psycho-social and spiritual-is critical to quality palliative care. In their average 55-minute initial consultation, about one-third of the time was spent on symptom management, with the other two-thirds of time spent on “patient and family coping” and “education about the illness.”[6,7]

In my view, even more emphasis should be placed on the importance of goal setting conversations between oncologists and patients as an important primary palliative care intervention. In their ambulatory palliative care guidelines, Jacobsen et al refer to “decision-making” discussion and recommend that oncologists “inquire about illness and prognostic understanding” and “offer clarification of treatment goals”.[7] The importance of these topics is highlighted by recent empirical studies observing an association between end-of-life discussions between oncologists and patients and lower rates of utilization of mechanical ventilation, cardiopulmonary resuscitation, and earlier hospice referrals.[8] Conversely, the study authors, Wright et al, found that patients who did not have appropriate end-of-life discussions with their providers were more likely to receive aggressive medical care in their last days of life and have lower quality of life scores, and their caregivers were more likely to be at higher risk for major depressive disorders.[8] These investigators noted that such discussions were not associated with higher rates of major depressive disorder or more worry.[8] The importance of the oncologist as a primary palliative care provider in this context is highlighted by Jacobsen et al; they recommend early outpatient palliative care consultations, noting that difficult end-of-life discussions are facilitated by patients who “experience palliative care… as an integrated part of oncology practice where difficult discussions with familiar palliative care clinicians appropriately follow the course of illness.”[7] This would suggest that the excellently trained oncologist, acting in the role of primary physician and palliative care provider, should be more effective than a consultant palliative care physician or team. We need better empirical data to confirm this hypothesis.

It is difficult to form firm conclusions concerning the efficacy of palliative care interventions because of substantial methodological limitations imparted by non-randomized study designs and the potential associated selection biases. For example, as pointed out by the investigators in the Wright et al study, it is possible that end-of-life discussions were associated with less aggressive end-of-life care because patients who initiated these discussions did so with a distinct preference for limiting care.[8] These methodological limitations to palliative care studies are unfortunately not uncommon given the complexity of the patients and the clinical scenarios,[9] and they highlight the basic point by Von Roenn and Temel that one needs to have clearly defined and measurable palliative care and supportive care interventions.[3]

Despite these caveats, palliative care research is becoming increasingly sophisticated and is building an evidentiary base by which one can evaluate the effectiveness and quality of care.[4,9] Integration of primary palliative care into mainstream oncologic practice will inevitably follow. The education and training of oncologists must include attention to the basic core competencies of palliative medicine, including symptom management and communication skills. The communication skills of the oncologist practicing primary palliative care must not only emphasize the understanding of patient preferences and the ability to empathically impart difficult prognostic news, but they should also include better teaching and training with respect to following up on the outcomes of these communications.

Financial Disclosure:The author is a paid consultant for Vitas Innovative Hospice Care, Inc.

References:

References

1. American Cancer Society. Cancer Facts and Figures, 2011. Available at www.cancer.org/Research/CancerFactsFigures/CancerFactsFigures/cancer-facts-figures-2011. Accessed October 30, 2011.

2. Saunders DC. Principles of symptom control in terminal care. Med Clin North Am. 1982;66:1169-83.

3. Von Roenn JH, Temel JS. The integration of palliative care and oncology: the evidence. Oncology (Williston Park). 2011. In press.

4. El-Jawahr A, Greer JA, Temel JS. Does palliative care improve outcomes for patients with incurable illness? A review of the evidence. Support Oncol. 2011;9:87-94.

5. von Gunten CF. Secondary and tertiary palliative care in US hospitals. JAMA. 2002;287:375-81.

6. Temel JS, Greer JA, Muzikanski A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363:733-8.

7. Jacobsen J, Jackson V, Dahlin C, et al. Components of early outpatient palliative care consultation in patients with metastatic nonsmall cell lung cancer. J Palliat Med. 2011;14:459-64.

8. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300:1665-73.

9. Zimmerman C, Riechelmann R, Krazyzanowsk M, et al. Effectiveness of specialized palliative care: a systematic review. JAMA. 2008;299:1698-1709.