ALEXANDRIA, Va. - Today the American Society of Clinical Oncology (ASCO) issued a provisional clinical opinion (PCO) recommending that all patients with metastatic non-small cell lung cancer (NSCLC) be offered palliative care along with standard cancer therapy, beginning at the time of diagnosis. While available evidence is strongest for metastatic lung cancer, the PCO also states that palliative care should be considered early in the course of care for patients with other metastatic cancers, and for those with a high burden of cancer-related symptoms.
The new evidence-based clinical guidance, published in the Journal of Clinical Oncology, was prompted by a growing body of research demonstrating the benefits of integrating palliative care into cancer therapy early in the course of care for patients with metastatic cancer.
Patients with metastatic cancer often live for months or years after their diagnosis, a period in which they can benefit from palliative care to improve the quality of life for both patients and caregivers. However, research has shown that many patients are not referred to specialized palliative care services or to hospice until near the end of life, lessening opportunities to address physical symptoms (e.g., pain, nausea and breathing difficulties) and meet the emotional, social and spiritual needs of patients and caregivers.
"Palliative care is about maintaining quality of life throughout the cancer journey," said Jamie Von Roenn, MD, co-author of the PCO and Professor of Medicine, Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University and Robert H. Lurie Comprehensive Cancer Center. "For patients with advanced cancer, the data are increasingly showing us that palliative care can be incredibly valuable for patients and their caregivers from the time they are diagnosed, not just at the end of life."
The PCO, titled "The Integration of Palliative Care into Standard Oncology Care," was developed by a panel of oncology and palliative experts convened by ASCO. The panel analyzed data from seven recently published randomized clinical trials involving patients with metastatic cancer that included a standard cancer care group and a "concurrent care" group, comprising patients receiving both standard cancer care and palliative care.
The review of evidence was initiated following the 2010 release of evidence from a phase III randomized clinical trial - sponsored in part by the Conquer Cancer Foundation of ASCO - finding that patients with metastatic NSCLC who received early palliative care together with standard oncology care had both improved quality of life and increased survival, compared to patients who received standard cancer care alone1.
While comparable evidence on survival for other metastatic cancers is not yet available, the review affirmed that the concurrent care approach caused no harm and was associated with a range of benefits, including comparable or improved survival, better symptom management, reduced depression, and improved caregiver and patient quality of life. Concurrent care was also associated with lower overall resource use and cost. They also found that palliative care was associated with earlier and more frequent hospice referral, which in turn relieves symptoms, caregiver burden, and may improve survival.
The PCO is one step in ASCO's ongoing efforts to ensure that patients with advanced cancer have access to high-quality palliative care. In early 2011, ASCO issued a policy statement, "Toward Individualized Care for Patients with Advanced Cancer," which recommended steps to ensure that physicians initiate candid discussions about the full range of palliative care and treatment options soon after a patient's diagnosis with advanced cancer. The statement was issued together with a booklet for patients, to help guide these difficult but important discussions.
Despite growing evidence supporting early palliative care for patients with metastatic cancer, authors of the PCO note that practical challenges exist to implementing this approach. A primary concern is that reimbursement for early palliative care is not consistently available for patients who are undergoing active cancer therapy in an outpatient setting and are not enrolled in hospice care. Additionally, more palliative care specialists will be needed to meet growing demand for these services. While oncologists are trained to provide important elements palliative care, such as pain and symptom relief, more specialized care is often important to address the complex needs of patients and their caregivers.
"Preserving quality of life is of utmost importance for all patients," said PCO co-author Tom Smith, MD, Professor of Oncology and Director of Palliative Care at Johns Hopkins. "We now have strong evidence in metastatic cancer that combining palliative care with standard cancer treatment improves our patients' lives in many ways and, in some cases, can help extend their lives. Patients deserve to have access to palliative care services and specialists throughout the course of their care."
The PCO authors also provided recommendations on areas where future research is needed to address important gaps in knowledge, such as the integration of palliative care into standard cancer care for other types of metastatic cancer, in addition to lung cancer, and which specific interventions have the most impact.
For a copy of the PCO, click here.
1 Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733-42, 2010
About Provisional Clinical Opinions: ASCO's Provisional Clinical Opinions are intended to offer evidence-based preliminary clinical direction to oncologists following the publication or presentation of potentially practice-changing data from major studies. ASCO develops PCOs, with a rigorous method, by convening a panel of experts on the issue, in accordance with the panel composition requirements of ASCO's Conflict of Interest Management Procedures for Clinical Practice Guidelines.