Supportive Oncology 2011: Living Better and Longer with Integrated Palliative Care Jason R. Beckrow, DO Hospice and Palliative Care Specialist Board Certified Medical Oncologist
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Supportive Oncology 2011: Living Better and Longer with Integrated Palliative Care Jason R. Beckrow, DO Hospice and Palliative Care Specialist Board Certified.
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Slide 1
Supportive Oncology 2011: Living Better and Longer with
Integrated Palliative Care Jason R. Beckrow, DO Hospice and
Palliative Care Specialist Board Certified Medical Oncologist
Slide 2
Disclosure Conflicts of interest-None I am employed by: Hospice
at Home, St. Joe & South Haven, Michigan Lighthouse Oncology -
South Haven, Michigan
Slide 3
Objectives At the completion of this lecture the learner will
understand: Integrated palliative care is synonymous with quality
cancer care. Recent research demonstrates that cancer patients
receiving early/integrated palliative care experience greater
quality of life and improved survivorship over patients with late
or no palliative care interventions.
Slide 4
Case Study Alvern B. 78 yo male Metastatic NSCLCA James B 69 yo
male Metastaic NSCLCA
Slide 5
Palliative Care Defined Person centered care for patients of
all ages who are experiencing a debilitating or life threatening
illness, condition or injury. The goal of palliative care is to
prevent and relieve suffering, including pain and psychosocial
distress. Palliative care is both a philosophy and an organized
structure of health care delivery.
Slide 6
Supportive Oncology The goal of supportive oncology is to
alleviate the suffering associated with: Cancer Diagnosis
Emotional/Psychological Spiritual/Existential Physical Cancer
Treatment Side Effects Sustain and improve quality of life Duke
Cancer Care Research Program Duke University Health System
Slide 7
Conceptual model for integration of palliative and supportive
care in oncology. Bruera E, Hui D JCO 2010;28:4013-4017 2010 by
American Society of Clinical Oncology
Slide 8
Conventional Care PresentationPresentationDeathDeath
Anti-disease Therapy Bereavement Care 6m6m Hospice Care
Slide 9
Palliative Care Therapies to modify disease Hospice Medicare
Benefit Presentation Therapies to relieve suffering and/or improve
quality of life Bereavement Care 6mDeath
Slide 10
Model of palliative cancer care. Ferris F D et al. JCO
2009;27:3052-3058 2009 by American Society of Clinical
Oncology
Slide 11
The use of a car is an analogy for setting goals of care.
Bruera E, Hui D JCO 2010;28:4013-4017 2010 by American Society of
Clinical Oncology
Slide 12
(A) A hopeful and unrealistic patient focuses on cancer cure
and life-prolongation measures, without paying attention to her
symptoms and advance care needs. Bruera E, Hui D JCO
2010;28:4013-4017 2010 by American Society of Clinical
Oncology
Slide 13
Slide 14
150 patients with newly diagnosed metastatic NSCLC Early
palliative care integrated with standard oncology care Standard
oncology care Baseline Data Collection RANDOMIZEDRANDOMIZED Study
Design Meet with palliative care within 3 weeks of signing consent
and at least monthly thereafter Meet with palliative care only when
requested by patient, family or oncology clinician.
Slide 15
Early Palliative Care Study Procedures Palliative Care
Guidelines Illness understanding and education Inquire about
illness and prognostic understanding Offer clarification regarding
treatment goals Distress Management Symptom management Pain
Pulmonary symptoms Fatigue and sleep disturbance Mood
Gastrointestinal Decision-making Assess mode of decision-making
Assist with treatment decision-making Coping with life-threatening
illness Patient Family/family caregivers
www.nationalconsensusproject.org
Slide 16
Distress Management Are We Missing Something Here?
Slide 17
Patients Reported Oncology Teams Often Do Not Consider
psychosocial care as a part of their patients cancer care
Understand their psychosocial needs, know about resources, or refer
when needed Presidents Cancer Panel 2003, 2004
Slide 18
Slide 19
Slide 20
Community Oncology Offices Cancer-Free Survival Managed Chronic
or Intermittent Disease Treatment Failure Treatment with Intent to
Cure Palliative Care Diagnosis and Staging Death Where majority of
cancer care is given today Where fewest psychological and social
services available
Slide 21
What patients want to know about their disease Patients say
they want to know the truth. Of 126 terminally ill patients, 98%
said they wanted their oncologists to be realistic. (Hagerty 2005)
Honesty associated with compassion and caring. Patients want
oncologists to be compassionate, stay the course, and be truthful.
(Kirk 2004) About 5-10% will not want to know. Reviewed in
Matsuyama R, Reddy S, Smith T. JCO 2006; Harrington & Smith
JAMA 2008
Slide 22
What patients know about their disease Matsuyama R, Reddy S,
Smith T. JCO 2006 35 small cell lung cancer patients learned more
about their prognosis from other patients than their doctors (The
et al, WJM 2001) Doctors did not want to give a death sentence
Patients did not want to hear it
Slide 23
What patients know about their disease Perspective of those
facing death Matsuyama R, Reddy S, Smith T. JCO 2006 We routinely
overestimate prognosis to patients with serious illness Meta-
analysis: 30-40% overestimate of time left (Glare 2003) Best study
of hospice: doctors overestimated to patients by 5.1: 1 (Christakis
and Lamont) We dont like to give bad news (Lamont 2002)
Slide 24
Panagopoulou, E. et al. J Clin Oncol; 26:1175-1177 2008 Why
don't we bring up the "D" word? It hurtsus. Task: Tell a 26 year
old woman she has inoperable brain tumor, live less than 2 years.
Randomized to 3 options: 1. Disclose complete information about
diagnosis, prognosis, and treatment. 2. Conceal the true diagnosis,
but still refer the patient for treatment. 3. Interview about
dietary habits. (control)
Slide 25
What patients know about their disease Perspective of those
facing death Matsuyama R, Reddy S, Smith T. JCO 2006 Solid tumor
patients who are over (falsely or un- realistically)-optimistic
dont live any longer (Weeks et al, JAMA 1998; Smith & Swisher
JAMA 1998) But are more likely to Die in ER Die in ICU Die on vent
Be readmitted with complications
Slide 26
Hope is maintained even with truthful discussions that teach
RR, PFS, OS, chance of cure, and transitions. Smith TJ, et al.
Oncology, 2010. Herth Hope Index Values Before and After
Educational Intervention 0 5 10 15 20 25 30 35 40 45 50
BeforeAfter
Slide 27
Study Objectives Primary Objective: Measure the difference in
QOL between the two study arms at 12 weeks. Secondary Objectives:
1.Psychological distress at 12 weeks 2.Quality of end-of-life care
3.Resource utilization at the end-of-life 4.Documentation of
resuscitation preference in the medical record
Slide 28
Study Eligibility 1.Metastatic NSCLC diagnosed within the
previous 8 weeks. 2.ECOG performance status 0-2. 3.Ability to read
and respond to questions in English. 4.Planning to receive oncology
care at the participating institution.
Slide 29
Effect of Early PC on 12-week Psychological Distress p=0.01
p=0.66 p=0.04
Slide 30
Standard care Survival Analysis Months Overall survival Median
Survival Early palliative care 11.6 mo Standard care 8.9 mo p=0.02
Early palliative care Controlling for age, gender and PS, adjusted
HR=0.59 (0.40-0.88), p=0.01
Slide 31
Summary Compared with standard oncology care, integrated
palliative care led to: Improvements in QOL Lower rates of
depression Less aggressive care at the end-of-life Greater
documentation of resuscitation preferences Higher survival
rates
Slide 32
Lighthouse Oncology Supportive Oncology Consultation Initial
Consultation: Metastatic and Locally Advanced Patients All
Performance Status Prior to initiation of Chemotherapy
Interventions per National Consensus Project Follow Up Q 2-6 weeks
Interventions per National Consensus Project
Slide 33
Early Palliative Care Study Procedures Palliative Care
Guidelines Illness understanding and education Inquire about
illness and prognostic understanding Offer clarification regarding
treatment goals Distress Management Symptom management Pain
Pulmonary symptoms Fatigue and sleep disturbance Mood
Gastrointestinal Decision-making Assess mode of decision-making
Assist with treatment decision-making Coping with life-threatening
illness Patient Family/family caregivers
www.nationalconsensusproject.org
Slide 34
Case Study Alvern B. 78 yo male Metastatic NSCLCA Chemotherapy
Supportive Care Time with Family ICU or Home James B 69 yo male
Metastaic NSCLCA Chemotherapy Supportive Care Long and Short term
goal setting. Garden
Slide 35
Thank You Eduardo Burrera, MD Charles van Gunten, MD Jimmie
Holland, MD T. J. Smith, MD. Jennifer Temel, MD Lawrence Feldman,
MD George Drake, MD Chris Strayhorn, M Div MD Steve Dupuis, DO
Linda Beushausen, RN, PhD Eric Lester, MD Sean ONeill, PhD
Questions?