Multidisciplinary approaches to palliative oncology care

There are an estimated 12.7 million cancer cases worldwide annually (1), with the global cancer burden continuing to increase each year and projected to reach to 22.2 million cases by 2030 (2,3). Cancer remains the leading cause of death in economically developed countries and the second leading cause of death in developing countries, with an estimated 7.6 million cancer deaths each year (1). Palliative care should ideally play a prominent role in these patients and others with advanced malignancies to reduce pain and suffering, promote quality of life, allow death with dignity, and support patient families and caregivers (4).

Cancer survival for many common malignancies is poorer in developing countries, likely due to a later stage at diagnosis and more limited access to timely and standard treatment (3). Despite cancer being a true global killer that is associated with significant patient morbidity and symptomatology, accessibility to palliative care services and medications is limited in many parts of the world. In this issue of Annals of Palliative Medicine (APM), Reville and Foxwell detail the current global state of palliative care and discuss challenges and barriers that remain in improving palliative care access and quality in oncology (5). Limited healthcare provider education about palliative care and lack of patient access to opioid analgesics remain major challenges to palliative care services for patients with cancer in many countries. Although significant progress has been made, Reville and Foxwell discuss strategies for improving access to palliative care programs (5).

Of paramount importance in improving oncology care in both developed and developing countries is the multidisciplinary approach of palliative care programs. Tuggey and Lewin detail how a multidisciplinary and interdisciplinary approach to oncology care can improve the patient and family illness experience (6). With a team approach to palliative care, diverse facets of care are possible, including pain and symptom management, social and spiritual assessment, discussion of illness, prognosis and treatment options, and identification of patient-centered goals of care.

The concept of advance care planning and its role in the care of patients with advanced malignancies are detailed in this issue of APM by Ranganathan et al. (7). These authors discuss the virtues of open communication between providers and patients and their families. Although this communication needs to be individualized, an open dialogue and honesty are critical to help the many patients diagnosed with late-stage malignancies better understand their disease and prognosis so that they can make informed decisions about their care.

This special issue on palliative care for advanced and metastatic malignancies also focuses on religion and spirituality, as well as integrative and complementary therapy. Richardson describes that most patients faced with life-threatening malignancies have spiritual needs that are not adequately addressed by their health care providers, and she discusses spiritual coping and methods that providers can use to deliver more holistic care to patients with cancer (8). Marchand describes how integrative medicine can combine the best of alternative, complementary, and conventional therapies to optimize well-being and quality of life for patients with cancer, and she discusses how integrative and complementary modalities can be included in comprehensive palliative care for patients with advanced malignancies. While integrative and complementary therapies also need to be individualized, Marchand provides an up-to-date and informative review of a number of modalities relevant to palliative care practitioners, including nutrition, movement, music, aromatherapy, massage, select supplements, and acupuncture (9).

Pain remains one of the most common symptoms among patients with cancer. Patients can experience pain from the tumor itself or from the therapies used to treat the malignancy, yet many patients remain inadequately treated for pain (10). In this issue, Ghosh and Berger have authored a comprehensive manuscript on analgesics and other options for pain management. They provide readers with methods of pain assessment for patients with cancer and detail the roles of opioids, intervational and injection therapies, implanted neurostimulation and neuraxial infusions, and adjuvant drugs like glucocorticoids, antidepressants, alpha-2 adrenergic agonists, cannabinoids, and topical therapies to manage pain experienced by patients with cancer (11).

Furthermore, palliative radiotherapy remains among the most effective methods for symptomatic control in advanced malignancies. Jones and Simone detail the role of palliative radiotherapy in managing cancer-related pain and in managing other common side effects experiences by patients with cancer, including symptoms from obstruction or central nervous system disease, as well as bleeding. They discuss a model for integrating radiotherapy within the context of a multidisciplinary palliative care program, expound upon the pros and cons of different palliative radiotherapy fractionation schedules, and describe when advanced radiotherapy techniques like intensity-modulated radiotherapy and stereotactic radiotherapy should appropriately be considered (12).

Systemic therapies also represent effective modalities for palliating symptoms, improving quality of life, and potentially prolonging survival of patients with advanced and metastatic malignancies. Based on the improvements in both quality of life and overall survival seen with chemotherapy in a number of malignancies, current clinical practice guidelines recommend that patients with advanced or metastatic cancer with good performance statuses be evaluated for systemic therapy (13). In this issue, Rajagopal et al. summarize the indications and benefits of recommended palliative chemotherapy regimens for several of the most common malignancies and provide readers with a foundation for discussions about systemic treatment of patients with advanced malignancies (14). Like with traditional cytotoxic chemotherapies, targeted therapies have emerged as front-line therapeutic and palliative treatments for a number of cancer types. Today, chemotherapy and targeted biological therapy are often personalized and based on a patient’s individual tumor biologic and molecular profile to optimize efficacy and minimize toxicity of treatment. Aggarwal describes how the availability of targeted therapies makes it easier to integrate early palliative and supportive care in the management of patients with advanced malignancies and summarizes recent advances in use of targeted therapy for patients with metastatic disease (15).

What is clear from this special issue of APM is that no single provider should work in isolation when caring for patients with advanced and metastatic malignancies. Delivering anti-cancer therapeutic treatments and addressing the various physical, psychosocial, and spiritual needs of patients and their families and caregivers requires a coordinated care team, the outlines for which are provided in this issue. Cancer remains among the most feared of all diseases and is commonly associated with death and dying. We hope this issue of APM will provide readers with added tools to improve communication with patients with cancer, address their fears, manage their symptoms, and provide holistic care to improve their quality of life.

Charles B. Simone II, MD. Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, PCAM, Department of Radiation Oncology, Philadelphia, PA 19104, USA. (Email: charles.simone@uphs.upenn.edu.)

Joshua A. Jones, MD, MA. Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, PCAM, Department of Radiation Oncology, Philadelphia, PA 19104, USA. (Email: Joshua.Jones@uphs.upenn.edu.)

Acknowledgements

Disclosure: The authors declare no conflict of interest.

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