Perspectives on screening tools to identify palliative care needs in patients with advanced cancer

Several randomized studies have shown that early palliative care referral can improve quality of life, satisfaction with care, and survival time in patients with advanced cancer (1-3). Therefore, many guidelines, including the American Society of Clinical Oncology (ASCO) practice guidelines, strongly recommend provision of palliative care concurrent with anticancer treatment (4). Nevertheless, patients’ unmet needs often remain high despite efforts by national and international organizations to place palliative care on the health agenda. According to World Health Organization estimates, only approximately 14% of people who currently need palliative care worldwide can receive it (5).

In a recent publication, Vetter presented a narrative review of palliative care screening tools in the gynecologic oncology population (6). As recommended in the ASCO guidelines (4), early palliative care can help to improve quality of life in patients with gynecologic cancer. Vetter concluded that numerous screening tools are worthy of further evaluation; these include the surprise question (SQ), presence of specific clinical triggers, Triggered Palliative Care Consultation, Palliative Care Referral Protocol, Patient-Reported Outcomes Measurement Information System, and Symptom screening with Targeted Early Palliative care. However, no definitive preferred screening tool has emerged in any oncology setting. To date, several palliative care screening tools for patients with advanced cancer have been developed. However, the advantages among these screening tools are unclear, and no standardized tools have been reported. The self-rated Three-Levels-of-Needs Questionnaire consists of fourteen items and is completed by patients (7). The Needs Assessment Tool: Progressive Disease-Cancer comprises eighteen items in three domains and was developed for completion by health care providers. This is the only multidimensional tool to concurrently assess the needs of both the patient and caregiver or family (8). The Screen for Palliative and End-of-Life Care Needs in the Emergency Department comprises thirteen items in five domains, with health care providers conducting assessment using this tool (9).

From a patient care perspective, patient-reported outcomes (PROs) can provide more accurate assessment (10), although PROs may be difficult for patients to report because of the complexity of their symptoms (11). Therefore, proxy assessment can complement the reporting of complex patient needs. For this reason, tools that incorporate both patient and proxy input can yield the best assessment to provide needs-based care. However, such tools may be burdensome in terms of clinicians’ time owing to a large number of items. This burden is critically important when promoting needs-based care because it has been reported that time is a factor affecting the accurate and timely identification of palliative care needs by clinicians (12). Therefore, brief palliative care screening tools with fewer items would be practical in clinical practice.

Several tools may be easy to use in clinical practice. The SQ can help clinicians to identify palliative care needs among patients with advanced cancer (13). The SQ is commonly stated as: “Would I be surprised if this patient were to die within the next X months?”. If the answer is “no”, this is suggested as a trigger for referral to palliative care (14). Reportedly, 41% to 79% of patients with advanced progressive diseases, including cancer, can be identified as having potential palliative care needs using the SQ (13,15,16). A meta-analysis review reported a wide degree of accuracy for the SQ as a prognostic tool (17). However, the SQ may be insufficient as a palliative care screening tool although it is very easy to use. Another instrument used increasingly in primary care worldwide is the Supportive and Palliative Care Indicator Tool (SPICT) (18). The SPICT consists of evidence-based clinical indicators of deteriorating health, including both generic and specific conditions. The SPICT is a clinical tool supporting health care professionals in the identification of older hospitalized patients at risk of dying within 12 months (18). Previous studies using the SPICT have reported that between 5.1% and 17.3% of elderly patients in primary care could benefit from palliative care (13,19,20). As for patients with advanced cancer, health care providers evaluate eight items in the SPICT. The burden in evaluation using the SPICT may be greater than that using the SQ but the SPICT may be less burdensome than other palliative care tools. Additionally, the SPICT has been used to develop an electronic records search tool called the AnticiPal (21). In a recent study to evaluate the utility of the AnticiPal, approximately 0.8% of 62,708 patients registered in general physician practices were identified as having potential palliative care needs (22). Furthermore, automated screening may avoid time-consuming screening of patients with palliative care needs, allowing clinicians to take a proactive approach in identifying patients with palliative care needs (23).

In our opinion, it remains unclear which tools are most advantageous in palliative care screening of patients with advanced cancer. The SQ may be easy to use, although clinicians’ subjectivity may influence their judgment despite an optimistic prognostication. Thus, we consider that the SPICT may be suitable for use in clinical practice because it offers greater objectivity than the SQ. Moreover, automated screening which includes use of artificial intelligence, might be helpful in its application versus other screening tools that include many assessment items. Further research on the selection of palliative care screening tools for patients with advanced cancer is highly warranted, considering the burden of implementation in clinical oncology practice.

Acknowledgments

We thank Analisa Avila, MPH, ELS, of Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-22-1322/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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