Early integration of palliative care in malignant hematology

Chan et al. contributes to the literature in their publication of “Supportive Care and Symptom Management in Patients with Advanced Hematological Malignancies: A Literature Review” addressing the significance of tailoring Palliative Care (PC) services for malignant hematology (MH) patients (1). However, evidence-based practices for early implementation of palliative care in MH populations are scarce (1). This scarcity can be attributed to several obstacles such as the difficulty in prognosticating MH, knowledge deficits regarding PC, and general barriers to access PC (2). In order to further contribute to the literature, it is imperative to address the importance of early implementation of palliative care, especially for MH populations.

In 1998, the American Society of Clinical Oncology (ASCO) (3) created an initiative that was committed to the worldwide comprehensive integration of palliative care in oncology by the year 2020 (4). The initiative was based on compelling research which demonstrated that early integration of palliative care improved quality of life (QOL) and satisfaction in persons diagnosed with lung cancer (5). Since this seminal research, palliative care implementation, for any cancer at any stage, has been shown to increase satisfaction and reduced stress (6). Despite these findings, several barriers still exist that make it more difficult to implement palliative cancer care for persons who need it (7). Chief among these barriers is lack of access to palliative care services for hematological malignancies.

Data shows that individuals are not referred for palliative services by their providers until they have reached advanced stages in cancer—at which point hospice care is the primary focus (8). In hematological malignancies, the average time lapsed between an initial PC consult and death is 13 and 46 days for solid malignancies (9). There seems to be a knowledge deficit specific to the goals of palliative versus hospice care, and most believe that palliative care equates to foregoing active cancer treatment (10). It also poses a moral dilemma for providers and patients that mistakenly equate PC services with a loss of hope and reduce efforts towards curative intent (1). Palliative care is distinct from hospice care, and it can be integrated concurrently with curative treatments from the time of diagnosis, through end-of-life supportive care. Palliative care is concerned with reducing symptom burden and improving function and QOL.

Individuals with a MH diagnosis experience an array of symptoms secondary to the nature of their disease and/or its treatments. Poor symptom management in MH can result in further complications or hasten death (11). When compared to non-hematological malignancies, MH patients are twice as likely to die in a hospital (12). M.D. Anderson Cancer Center conducted a study that demonstrated the greatest predictor for poor QOL at end-of-life (EOL) was a hematological malignancy diagnosis (1). Hematologist Oncologists are much more likely to prescribe moderately toxic systemic therapy without proven survival benefit to a patient with a prognosis of less than one month of life. In part, it is believed that MH Oncologist believe treatment is the best form of palliation in their patient population. For example, in some instances a packed marrow may cause a patient to become transfusion dependent, therefore, treatment may in fact improve QOL if they can become less dependent on transfusions. This highlights how essential it is for MH patients to have earlier access to palliative care. Prognosticating MH patients is difficult and therefore increasing MH patients’ access to PC from the point of diagnosis may actually improve EOL planning, QOL and overall patient understanding of disease trajectory (13).

Individuals with increased access to palliative care experience increased QOL, increased mood scores, and better symptom management (14,15). Early referral to palliative care (within eight weeks of diagnosis for all cancer stages) resulted in better survival, improved QOL—similar to the effects of first-line chemotherapy, reduced hospitalizations, reduced health related expenses and decreased the likelihood of individuals receiving chemotherapy in the last six weeks of life (5,16). Perhaps one possible solution to this disparity of early PC services in MH patients is to provide more specialized PC teams that have a robust understanding of the needs in this specialty.

Specialized interdisciplinary care teams (IDTs) in palliative care for adult oncology populations improved health related QOL and improved overall participant symptoms (11,17). It was also found that regardless of whether a person was receiving chemotherapy or not, persons with cancer receiving palliative care had an increased QOL (6). Therefore, early implementation of these IDT for MH can only benefit the patient’s experience throughout their disease trajectory. Providing persons with cancer with psychosocial education regarding palliative care, increases their acceptance of palliative care and overall satisfaction with care (10,18). Better education and palliative symptom management in terminally ill individuals with chronic conditions, such as cancer, was associated with increased satisfaction with care and QOL, and decreased hospital expenses (6,19,20).

The World Health Organization (WHO) is seeking to improve health internationally by incorporating palliative care programs earlier in the illness trajectory, and asserts that palliative services should be available early and based on individuals’ needs rather than poor prognosis (21). It is estimated that if palliative services were fully implemented, the US would save approximately $6 billion a year (22). Although 67% of US hospitals have implemented palliative care teams, there is less focus and information available for the implementation of these services at the community level (22,23). This demonstrates an opportunity to improve access to palliative care for hematologic malignancies and a need for earlier implementation of palliative care services starting at community levels.

In conclusion, delayed referrals that result from providers’ knowledge deficit may lead to reduced access to palliative care, a QOL issue in the cancer population (5,10). Addressing knowledge deficits regarding the role and purpose of palliative care can help to increase patient access to palliative services (5,24). Previous research indicates that optimal results may be achieved for persons with cancer by granting access to palliative services within eight weeks of initial diagnosis (5,6,20). In order to accomplish earlier referrals, healthcare providers must understand that palliative care services are not limited to terminal patients (12). Patients must also be taught that palliative care is distinct from hospice in that they can co-receive palliative care and curative treatments, whereas with hospice, one cannot receive curative treatment (10,14,25). The WHO and ASCO believe palliative care should be available early to individuals irrespective of stage of disease. The biggest impediment to the application of such programs is knowledge deficits amongst providers and individuals undergoing medical care. This article is meant to acknowledge the contributions to the literature by Chan et al. and encourage additional studies regarding the early implementation of PC for malignant hematology (1).

Acknowledgments

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-23-244/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/.

References

1. Chan KY, Chan TSY, Gill H, et al. Supportive care and symptom management in patients with advanced hematological malignancies: a literature review. Ann Palliat Med 2022;11:3273-91. [Crossref] [PubMed]
2. Ferraz LFM, Ferreira APS, Guimarães TVV, et al. Early integration of palliative care in hematology: an urgency for patients, a challenge for physicians. Hematol Transfus Cell Ther 2022;44:567-73. [Crossref] [PubMed]
3. Cancer Society- Cancer Facts and Figures (2019). Atlanta, GA: American Cancer Society. Available online: https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2019.html
4. Ferris FD, Bruera E, Cherny N, et al. Palliative cancer care a decade later: accomplishments, the need, next steps -- from the American Society of Clinical Oncology. J Clin Oncol 2009;27:3052-8. [Crossref] [PubMed]
5. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-42. [Crossref] [PubMed]
6. Howie L, Peppercorn J. Early palliative care in cancer treatment: rationale, evidence and clinical implications. Ther Adv Med Oncol 2013;5:318-23. [Crossref] [PubMed]
7. Kain DA, Eisenhauer EA. Early integration of palliative care into standard oncology care: evidence and overcoming barriers to implementation. Curr Oncol 2016;23:374-7. [Crossref] [PubMed]
8. Wentlandt K, Krzyzanowska MK, Swami N, et al. Referral practices of oncologists to specialized palliative care. J Clin Oncol 2012;30:4380-6. [Crossref] [PubMed]
9. Fadul NA, El Osta B, Dalal S, et al. Comparison of symptom burden among patients referred to palliative care with hematologic malignancies versus those with solid tumors. J Palliat Med 2008;11:422-7. [Crossref] [PubMed]
10. Hoerger M, Barkan T, Perry L, et al. Increasing patients' preferences for palliative care through the dissemination of palliative care research: Impact of socioeconomic status, geography, and depression severity. J Clin Oncol 2015;33:109. [Crossref]
11. Ferrell B, Sun V, Hurria A, et al. Interdisciplinary Palliative Care for Patients With Lung Cancer. J Pain Symptom Manage 2015;50:758-67. [Crossref] [PubMed]
12. Hui D, Kim SH, Roquemore J, et al. Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer 2014;120:1743-9. [Crossref] [PubMed]
13. Shaulov A, Aviv A, Alcalde J, et al. Early integration of palliative care for patients with haematological malignancies. Br J Haematol 2022;199:14-30. [Crossref] [PubMed]
14. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA 2009;302:741-9. [Crossref] [PubMed]
15. Slovacek L, Slovackova B, Slanska I, et al. Depression symptoms and health-related quality of life among patients with metastatic breast cancer in programme of palliative cancer care. Neoplasma 2009;56:467-72. [Crossref] [PubMed]
16. Rugno FC, Paiva BS, Paiva CE. Early integration of palliative care facilitates the discontinuation of anticancer treatment in women with advanced breast or gynecologic cancers. Gynecol Oncol 2014;135:249-54. [Crossref] [PubMed]
17. Salins N, Ramanjulu R, Patra L, et al. Integration of Early Specialist Palliative Care in Cancer Care and Patient Related Outcomes: A Critical Review of Evidence. Indian J Palliat Care 2016;22:252-7. [Crossref] [PubMed]
18. Hannon B, Swami N, Pope A, et al. Early Palliative Care and Its Role in Oncology: A Qualitative Study. Oncologist 2016;21:1387-95. [Crossref] [PubMed]
19. Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc 2007;55:993-1000. [Crossref] [PubMed]
20. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014;383:1721-30. [Crossref] [PubMed]
21. Lipman AG. Palliative care for older people: Better practices. Journal of Pain & Palliative Care Pharmacotherapy 2012;26:81. [Crossref]
22. Dumanovsky T, Augustin R, Rogers M, et al. The Growth of Palliative Care in U.S. Hospitals: A Status Report. J Palliat Med 2016;19:8-15. [Crossref] [PubMed]
23. Morrison RS. Models of palliative care delivery in the United States. Curr Opin Support Palliat Care 2013;7:201-6. [Crossref] [PubMed]
24. Hoerger M, Perry LM, Gramling R, et al. Does educating patients about the Early Palliative Care Study increase preferences for outpatient palliative cancer care? Findings from Project EMPOWER. Health Psychol 2017;36:538-48. [Crossref] [PubMed]
25. Reville B, Foxwell AM. The global state of palliative care-progress and challenges in cancer care. Ann Palliat Med 2014;3:129-38. [PubMed]